Provider Demographics
NPI:1902113244
Name:START FRESH ALCOHOL RECOVERY CLINIC
Entity Type:Organization
Organization Name:START FRESH ALCOHOL RECOVERY CLINIC
Other - Org Name:FRESH START PRIVATE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:FALLIERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-541-6100
Mailing Address - Street 1:720 NORTH TUSTIN AVE , SUIT #206
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3606
Mailing Address - Country:US
Mailing Address - Phone:714-541-6100
Mailing Address - Fax:714-541-9002
Practice Address - Street 1:720 NORTH TUSTIN AVE , SUIT #206
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3606
Practice Address - Country:US
Practice Address - Phone:714-541-6100
Practice Address - Fax:714-541-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical