MEDICARE: FRESH START OF MIAMI-DADE, INC.

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	251X00000X	Supports Brokerage Agency

General Provider Information

NPI Number	:	1912294745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH START OF MIAMI-DADE, INC.

Provider Business Mailing Address
First Line	:	18441 NW 2ND AVE
Second Line	:	SUITE 106-108
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4517
Country	:	US
Telephone Number	:	305-623-9937
Fax Number	:	305-623-9917

Provider Business Practice Location Address
First Line	:	18441 NW 2ND AVE
Second Line	:	SUITE 106-108
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4517
Country	:	US
Telephone Number	:	305-623-9937
Fax Number	:	305-623-9917

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SANDRA MCQUEEN-BAKER
Credential	:
Telephone Number	:	305-623-9937

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	10/09/2013

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