MEDICARE: GOD AND FRESH FAMILY CHIROPRACTIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	B1001	NV

General Provider Information

NPI Number	:	1174570592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOD AND FRESH FAMILY CHIROPRACTIC

Provider Business Mailing Address
First Line	:	7240 W LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-8356
Country	:	US
Telephone Number	:	702-453-0440
Fax Number	:	702-453-0550

Provider Business Practice Location Address
First Line	:	7240 W LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-8356
Country	:	US
Telephone Number	:	702-453-0440
Fax Number	:	702-453-0550

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN FRESH
Credential	:
Telephone Number	:	702-453-0440

Provider Enumeration Date	:	05/30/2006
Last Update Date	:	08/22/2020

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