MEDICARE: LMS FRESHSTART LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	NV20171166360	NV

General Provider Information

NPI Number	:	1093249484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LMS FRESHSTART LLC

Provider Business Mailing Address
First Line	:	187 RUIDOSO LN
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074
Country	:	UM
Telephone Number	:	602-592-0503
Fax Number	:

Provider Business Practice Location Address
First Line	:	4660 S EASTERN AVE STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6139
Country	:	US
Telephone Number	:	702-478-8205
Fax Number	:	702-478-5266

Authorized Official
Title or Position	:	OWNER
Name	:	MERCEDES KENISHA WARD
Credential	:
Telephone Number	:	602-639-3506

Provider Enumeration Date	:	04/12/2017
Last Update Date	:	04/12/2017

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