Provider Demographics
NPI:1780395277
Name:FRESH START CLUBHOUSE, INC.
Entity type:Organization
Organization Name:FRESH START CLUBHOUSE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WEBB
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:734-929-9992
Mailing Address - Street 1:211 E MICHIGAN AVE UPPR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5677
Mailing Address - Country:US
Mailing Address - Phone:734-929-9992
Mailing Address - Fax:
Practice Address - Street 1:211 E MICHIGAN AVE UPPR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5677
Practice Address - Country:US
Practice Address - Phone:734-929-9992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)