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General NPI Number Information
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NPI Number | 1548497795
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Entity Type | Organization
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Legal Business Name | FRESH START SERVICE SUPPORT
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Dates
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Enumeration Date | 06/15/2009
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Last Update Date | 06/15/2009
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Provider Practice Location Address
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Address Line | 4708 MEADOWCROFT RD
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City | GREENSBORO
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State | NC
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Zip | 27406-8085
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Country | US
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Telephone | 336-988-7339
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Fax |
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Provider Business Mailing Address
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Address Line | 4708 MEADOWCROFT RD
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City | GREENSBORO
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State | NC
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Zip | 27406-8085
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Country | US
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Telephone | 336-988-7339
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR, PARAPROFESSIONAL
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Name | MS. CHRISTAL SMITH
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Credential |
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Telephone | 336-988-7339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | MHL-041-907
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License Number State | NC
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