Healthcare Provider Details

I. General information

NPI: 1023724861
Provider Name (Legal Business Name): FRESH START RECOVERY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3464 STELLHORN RD
FORT WAYNE IN
46815-4630
US

IV. Provider business mailing address

11788 WHISTLING TRL
FORT WAYNE IN
46818-0144
US

V. Phone/Fax

Practice location:
  • Phone: 260-402-9145
  • Fax:
Mailing address:
  • Phone: 260-402-1503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: EAMON CHRISTOPHER POOR
Title or Position: OFFICE MANAGER
Credential:
Phone: 260-402-1503