Healthcare Provider Details

I. General information

NPI: 1477256378
Provider Name (Legal Business Name): FRESH START IC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9118 N CAVE CREEK RD
PHOENIX AZ
85020-2525
US

IV. Provider business mailing address

PO BOX 26063
PHOENIX AZ
85068-6063
US

V. Phone/Fax

Practice location:
  • Phone: 480-900-7622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELICA ZEPEDA
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 480-749-0282