MEDICARE: OPERATION FRESH START

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	70968030	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41868000	OTHER	WI	MEDICARE PROVIDER CERTIFICATION

General Provider Information

NPI Number	:	1841466208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPERATION FRESH START

Provider Business Mailing Address
First Line	:	1925 WINNEBAGO ST
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-5314
Country	:	US
Telephone Number	:	608-244-4721
Fax Number	:	608-244-8162

Provider Business Practice Location Address
First Line	:	1925 WINNEBAGO ST
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-5314
Country	:	US
Telephone Number	:	608-244-4721
Fax Number	:	608-244-8162

Authorized Official
Title or Position	:	DEPUTY DIRECTOR
Name	:	JIM SANDERS
Credential	:	MS, LPC
Telephone Number	:	608-244-4721

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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Directions to “OPERATION FRESH START ” Practice Location

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