=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760609929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRESH START SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2521 APRICOT LN
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89108-3555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-631-3319
-----------------------------------------------------
Fax | 702-631-0051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 570924
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89157-0924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-631-3319
-----------------------------------------------------
Fax | 702-631-0051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. GIRMA ZAID
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 702-631-3319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------