Healthcare Provider Details

I. General information

NPI: 1518612613
Provider Name (Legal Business Name): A FRESH START RECOVERY HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 W NORTH AVE
MILWAUKEE WI
53208-1415
US

IV. Provider business mailing address

PO BOX 12773
MILWAUKEE WI
53212-0773
US

V. Phone/Fax

Practice location:
  • Phone: 414-600-9947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: REEIYAINA GRIFFIN
Title or Position: AGENT
Credential:
Phone: 414-815-0505