Provider Demographics
NPI:1477623981
Name:FRESH START, INC.
Entity Type:Organization
Organization Name:FRESH START, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:216-431-2554
Mailing Address - Street 1:2415 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-1501
Mailing Address - Country:US
Mailing Address - Phone:216-431-2554
Mailing Address - Fax:216-431-4878
Practice Address - Street 1:4807 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4437
Practice Address - Country:US
Practice Address - Phone:216-431-4979
Practice Address - Fax:216-431-5793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06955324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01074Medicare UPIN