Basic Information
| Provider Information | |||||||||
| NPI: | 1144809088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRESH START RECOVERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15886 GAITHER DR STE B | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208771404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448146862 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15886 GAITHER DR STE B | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208771404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448146862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2021 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | COSTLEY | ||||||||
| AuthorizedOfficialFirstName: | JESSIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4108078471 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRESH START RECOVERY CENTER LLC | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.