Healthcare Provider Details

I. General information

NPI: 1508728023
Provider Name (Legal Business Name): A FRESH START SOUTHERN SUPPORT RECOVERY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 GLOVERS CROSS RD
COLERAIN NC
27924-9449
US

IV. Provider business mailing address

327 GLOVERS CROSS RD
COLERAIN NC
27924-9449
US

V. Phone/Fax

Practice location:
  • Phone: 252-642-5345
  • Fax:
Mailing address:
  • Phone: 252-642-5345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICKIE M PERSAUD
Title or Position: MANAGING MEMBER
Credential:
Phone: 252-642-5345