Healthcare Provider Details

I. General information

NPI: 1154942829
Provider Name (Legal Business Name): FRESH START BONE AND JOINT INSTITUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S WATSON RD STE 103-438
BUCKEYE AZ
85326-3452
US

IV. Provider business mailing address

485 S WATSON RD STE 103-438
BUCKEYE AZ
85326-3452
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-9777
  • Fax: 623-236-3197
Mailing address:
  • Phone: 623-535-9777
  • Fax: 623-236-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: LIZETH RIVAS
Title or Position: BILLING MANAGER
Credential:
Phone: 623-535-9777