Basic Information
| Provider Information | |||||||||
| NPI: | 1164830501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | START FRESH CENTRAL VALLEY RECOVERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25042 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937295042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594381245 | ||||||||
| FaxNumber: | 5598924500 | ||||||||
| Practice Location | |||||||||
| Address1: | 6073 N 1ST ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937105444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592023830 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2014 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | GRAHAM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5592023830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 2084A0401X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
No ID Information.