Provider Demographics
NPI:1497150007
Name:START FRESH ALCOHOL RECOVERY CLINIC, INC
Entity Type:Organization
Organization Name:START FRESH ALCOHOL RECOVERY CLINIC, INC
Other - Org Name:START FRESH RECOVERY LAS VEGAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:N
Authorized Official - Last Name:FALLIERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-919-0000
Mailing Address - Street 1:501 S RANCHO DR STE H50
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4828
Mailing Address - Country:US
Mailing Address - Phone:702-919-0000
Mailing Address - Fax:702-476-9411
Practice Address - Street 1:501 S RANCHO DR STE H50
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4828
Practice Address - Country:US
Practice Address - Phone:702-919-0000
Practice Address - Fax:702-476-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15522207RA0401X
261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV15522OtherSTATE LICENSE