Provider Demographics
NPI:1184158826
Name:FRESH START RECOVERY LAB
Entity type:Organization
Organization Name:FRESH START RECOVERY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-234-2469
Mailing Address - Street 1:15886 GAITHER DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1404
Mailing Address - Country:US
Mailing Address - Phone:954-234-2469
Mailing Address - Fax:954-204-0464
Practice Address - Street 1:15886 GAITHER DR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1404
Practice Address - Country:US
Practice Address - Phone:954-234-2469
Practice Address - Fax:954-204-0464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESH START RECOVERY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D2127826291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21D2127826OtherCENTER MEDICARE MEDICAID