=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669949566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRESH START VEGAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2018
-----------------------------------------------------
Last Update Date | 10/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 S 4TH ST STE 500
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89101-6207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-849-0460
-----------------------------------------------------
Fax | 702-920-7648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 S 4TH ST STE 500
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89101-6207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-849-0460
-----------------------------------------------------
Fax | 702-920-7648
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROSSI POOLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-849-0460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------