Healthcare Provider Details

I. General information

NPI: 1295272482
Provider Name (Legal Business Name): FRESH START RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15886 GAITHER DR SUITE B
GAITHERSBURG MD
20877-1404
US

IV. Provider business mailing address

15886 GAITHER DR SUITE B
GAITHERSBURG MD
20877-1404
US

V. Phone/Fax

Practice location:
  • Phone: 301-300-3696
  • Fax: 954-298-4039
Mailing address:
  • Phone: 301-300-3696
  • Fax: 954-298-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberD0046457
License Number StateMD

VIII. Authorized Official

Name: JESSIE COSTLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 443-839-6928