Provider Demographics
NPI:1053149211
Name:SHINING STAR PSYCHIATRIC CARE LLC
Entity type:Organization
Organization Name:SHINING STAR PSYCHIATRIC CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON PRIMUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-470-9371
Mailing Address - Street 1:2807 N PARHAM RD STE 311
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2807 N PARHAM RD STE 311
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4410
Practice Address - Country:US
Practice Address - Phone:940-249-0272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-22
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty