Healthcare Provider Details

I. General information

NPI: 1497150007
Provider Name (Legal Business Name): START FRESH ALCOHOL RECOVERY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S RANCHO DR STE H50
LAS VEGAS NV
89106-4828
US

IV. Provider business mailing address

501 S RANCHO DR STE H50
LAS VEGAS NV
89106-4828
US

V. Phone/Fax

Practice location:
  • Phone: 702-919-0000
  • Fax: 702-476-9411
Mailing address:
  • Phone: 702-919-0000
  • Fax: 702-476-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number15522
License Number StateNV

VIII. Authorized Official

Name: GEORGE N FALLIERAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 702-919-0000