Provider Demographics
NPI:1598147266
Name:FRESH START PRIVATE MIDWEST LLC
Entity Type:Organization
Organization Name:FRESH START PRIVATE MIDWEST LLC
Other - Org Name:START FRESH ALCOHOL RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRIFFITH
Authorized Official - Middle Name:F
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-884-1221
Mailing Address - Street 1:2827 S 88TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3056
Mailing Address - Country:US
Mailing Address - Phone:402-884-1221
Mailing Address - Fax:402-884-1335
Practice Address - Street 1:2827 S 88TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3056
Practice Address - Country:US
Practice Address - Phone:402-884-1221
Practice Address - Fax:402-884-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207LPZ900X207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE508729194Medicaid
087208Medicare PIN
NE508729194Medicaid