Healthcare Provider Details

I. General information

NPI: 1164830501
Provider Name (Legal Business Name): START FRESH CENTRAL VALLEY RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6073 N 1ST ST STE 102
FRESNO CA
93710-5444
US

IV. Provider business mailing address

PO BOX 25042
FRESNO CA
93729-5042
US

V. Phone/Fax

Practice location:
  • Phone: 559-202-3830
  • Fax:
Mailing address:
  • Phone: 559-438-1245
  • Fax: 559-892-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT GRAHAM
Title or Position: SUPERVISING PHYSICIAN
Credential: M.D.
Phone: 559-202-3830