Provider Demographics
NPI:1316187032
Name:SUPPORTING BRIGHT STARS, LLC
Entity type:Organization
Organization Name:SUPPORTING BRIGHT STARS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YEZENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-334-6768
Mailing Address - Street 1:1463 OAKFIELD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-3893
Mailing Address - Country:US
Mailing Address - Phone:813-655-4166
Mailing Address - Fax:813-655-4814
Practice Address - Street 1:1463 OAKFIELD DR STE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-3893
Practice Address - Country:US
Practice Address - Phone:813-655-4166
Practice Address - Fax:813-655-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-21
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center