Provider Demographics
NPI:1689182792
Name:FRESH START COMMUNITY HEALTH CENTER LLC
Entity Type:Organization
Organization Name:FRESH START COMMUNITY HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DINKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-688-8190
Mailing Address - Street 1:351 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-4819
Mailing Address - Country:US
Mailing Address - Phone:318-779-0873
Mailing Address - Fax:
Practice Address - Street 1:351 W 79TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-688-8190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-11
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care