Healthcare Provider Details

I. General information

NPI: 1821220138
Provider Name (Legal Business Name): FRESH START DIALYSIS SPA TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MERCANTILE LN
LARGO MD
20774-5360
US

IV. Provider business mailing address

719 STREAMSIDE DR
BOWIE MD
20721-1803
US

V. Phone/Fax

Practice location:
  • Phone: 240-606-7828
  • Fax:
Mailing address:
  • Phone: 240-606-7828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. TAHISHA B. BROOKS
Title or Position: PRESIDENT & CEO
Credential:
Phone: 240-606-7828