Provider Demographics
NPI:1154371995
Name:P. STARK ENTERPRISES, INC.
Entity type:Organization
Organization Name:P. STARK ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-388-3766
Mailing Address - Street 1:1100 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3530
Mailing Address - Country:US
Mailing Address - Phone:931-388-3766
Mailing Address - Fax:
Practice Address - Street 1:1100 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3530
Practice Address - Country:US
Practice Address - Phone:931-388-3766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P. STARK ENTERPRISES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000405332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454165Medicaid
TN1454165Medicaid