Provider Demographics
NPI:1548627961
Name:STELLAR LIVING ENTERPRISES , INC
Entity type:Organization
Organization Name:STELLAR LIVING ENTERPRISES , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEXTER
Authorized Official - Middle Name:DESHA
Authorized Official - Last Name:WEATHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-806-1380
Mailing Address - Street 1:2191 PINETOP LN
Mailing Address - Street 2:UNIT # 108
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-7812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2191 PINETOP LN
Practice Address - Street 2:UNIT # 108
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7812
Practice Address - Country:US
Practice Address - Phone:702-806-1380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-16
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization