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General NPI Number Information
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NPI Number | 1295272482
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Entity Type | Organization
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Legal Business Name | FRESH START RECOVERY CENTER LLC
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Dates
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Enumeration Date | 01/25/2017
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Last Update Date | 04/07/2021
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Provider Practice Location Address
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Address Line | 15886 GAITHER DR SUITE B
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City | GAITHERSBURG
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State | MD
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Zip | 20877-1404
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Country | US
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Telephone | 301-300-3696
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Fax | 954-298-4039
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Provider Business Mailing Address
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Address Line | 15886 GAITHER DR SUITE B
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City | GAITHERSBURG
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State | MD
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Zip | 20877-1404
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Country | US
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Telephone | 301-300-3696
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Fax | 954-298-4039
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | JESSIE COSTLEY
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Credential |
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Telephone | 443-839-6928
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | D0046457
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License Number State | MD
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