Provider Demographics
NPI:1023724861
Name:FRESH START RECOVERY GROUP LLC
Entity type:Organization
Organization Name:FRESH START RECOVERY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EAMON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:POOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-402-1503
Mailing Address - Street 1:11788 WHISTLING TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-0144
Mailing Address - Country:US
Mailing Address - Phone:260-402-1503
Mailing Address - Fax:
Practice Address - Street 1:3464 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4630
Practice Address - Country:US
Practice Address - Phone:260-402-9145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty