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General NPI Number Information
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NPI Number | 1710039086
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Entity Type | Organization
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Legal Business Name | FRESH START RESIDENTIAL FACILITY, INC
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 7866 ADRIAN DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28314-6312
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Country | US
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Telephone | 910-867-3591
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Fax |
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Provider Business Mailing Address
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Address Line | 7866 ADRIAN DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28314-6312
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Country | US
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Telephone | 910-867-3591
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DEMONTAY RAMEL MUNFORD
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Credential |
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Telephone | 910-867-3591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 026-822
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License Number State | NC
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