Provider Demographics
NPI:1295272482
Name:FRESH START RECOVERY CENTER LLC
Entity type:Organization
Organization Name:FRESH START RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-839-6928
Mailing Address - Street 1:15886 GAITHER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1404
Mailing Address - Country:US
Mailing Address - Phone:301-300-3696
Mailing Address - Fax:954-298-4039
Practice Address - Street 1:15886 GAITHER DR
Practice Address - Street 2:SUITE B
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1404
Practice Address - Country:US
Practice Address - Phone:301-300-3696
Practice Address - Fax:954-298-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046457261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder