MEDICARE: FRESH FOCUS INNOVATIONS, LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1588147607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH FOCUS INNOVATIONS, LLC

Provider Business Mailing Address
First Line	:	8520 BEAVER CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-2821
Country	:	US
Telephone Number	:	864-567-6057
Fax Number	:

Provider Business Practice Location Address
First Line	:	4921 BRIDLE PATH LN
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3615
Country	:	US
Telephone Number	:	803-816-2155
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JASMINE LUSTER
Credential	:	LPC
Telephone Number	:	803-816-2155

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	10/03/2019

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