MEDICARE: FRESH START HOME COMMUNITY DEVELOPMENT CORPORATION

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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1992416556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH START HOME COMMUNITY DEVELOPMENT CORPORATION

Provider Business Mailing Address
First Line	:	5168 S MICHIGAN AVE UNIT 4N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-3313
Country	:	US
Telephone Number	:	312-632-0811
Fax Number	:

Provider Business Practice Location Address
First Line	:	7003 S NORMAL BLVD APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3064
Country	:	US
Telephone Number	:	312-632-0811
Fax Number	:	855-267-5262

Authorized Official
Title or Position	:	PRESIDENT/EXECUTIVE DIRECTOR
Name	:	MRS. VIANNA C. LITTLE
Credential	:
Telephone Number	:	312-632-0811

Provider Enumeration Date	:	12/05/2022
Last Update Date	:	12/05/2022

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