Healthcare Provider Details

I. General information

NPI: 1902113244
Provider Name (Legal Business Name): START FRESH ALCOHOL RECOVERY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 NORTH TUSTIN AVE , SUIT #206
SANTA ANA CA
92705-3606
US

IV. Provider business mailing address

720 NORTH TUSTIN AVE , SUIT #206
SANTA ANA CA
92705-3606
US

V. Phone/Fax

Practice location:
  • Phone: 714-541-6100
  • Fax: 714-541-9002
Mailing address:
  • Phone: 714-541-6100
  • Fax: 714-541-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE NICHOLAS FALLIERAS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 714-541-6100