MEDICARE: FRESH START, INC.

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	324500000X	Substance Abuse Rehabilitation Facility	06955	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235175480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH START, INC.

Provider Business Mailing Address
First Line	:	2415 E 55TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-1501
Country	:	US
Telephone Number	:	216-431-2554
Fax Number	:	216-431-4878

Provider Business Practice Location Address
First Line	:	2415 E 55TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-1501
Country	:	US
Telephone Number	:	216-431-2554
Fax Number	:	216-431-4878

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MS. RUBY J BLACK
Credential	:	M.ED.
Telephone Number	:	216-431-2554

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	08/22/2020

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Directions to “FRESH START, INC. ” Practice Location

Language	Start Address	Practice Location

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