Provider Demographics
NPI:1164830501
Name:START FRESH CENTRAL VALLEY RECOVERY
Entity Type:Organization
Organization Name:START FRESH CENTRAL VALLEY RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-202-3830
Mailing Address - Street 1:PO BOX 25042
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5042
Mailing Address - Country:US
Mailing Address - Phone:559-438-1245
Mailing Address - Fax:559-892-4500
Practice Address - Street 1:6073 N 1ST ST STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5444
Practice Address - Country:US
Practice Address - Phone:559-202-3830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty