MEDICARE: FRESH BEGINNINGS LIFE CHANGING ORGANIZATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2080P0006X	Developmental - Behavioral Pediatrics Physician
2	3245S0500X	Children's Substance Abuse Rehabilitation Facility
3	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

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	:	1710509252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH BEGINNINGS LIFE CHANGING ORGANIZATION

Provider Business Mailing Address
First Line	:	PO BOX 40292
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77240-0292
Country	:	US
Telephone Number	:	713-530-4192
Fax Number	:

Provider Business Practice Location Address
First Line	:	7863 LUMBER JACK DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-1740
Country	:	US
Telephone Number	:	713-530-4192
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	WYNNETTE WILLIAMS
Credential	:
Telephone Number	:	713-530-4192

Provider Enumeration Date	:	05/07/2020
Last Update Date	:	05/07/2020

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