Provider Demographics
NPI:1255466827
Name:FRESH START RESIDENTIAL SERVICES INC
Entity Type:Organization
Organization Name:FRESH START RESIDENTIAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-790-7869
Mailing Address - Street 1:2411 E MILLBROOK RD STE 114
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2800
Mailing Address - Country:US
Mailing Address - Phone:919-790-7869
Mailing Address - Fax:919-790-7864
Practice Address - Street 1:5039 SEDGEWICK DR APT D
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-4576
Practice Address - Country:US
Practice Address - Phone:919-790-7869
Practice Address - Fax:919-790-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 092 449322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children