=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477206886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRESH START HEALTH PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2022
-----------------------------------------------------
Last Update Date | 06/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 N CAROL MALONE BLVD STE 3
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41143-1566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-225-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 N CAROL MALONE BLVD STE 3
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41143-1566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-225-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | JERREL H BOYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 606-922-2895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------