Provider Demographics
NPI:1578218665
Name:A FRESH START RECOVERY HOUSE
Entity Type:Organization
Organization Name:A FRESH START RECOVERY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:REEIYAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-600-9947
Mailing Address - Street 1:PO BOX 12773
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-0773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3505 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1415
Practice Address - Country:US
Practice Address - Phone:414-600-9947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000000000Medicaid