1598581647 NPI number — CLEAN SLATE ADULT FAMILY HOME CORP.

Table of content: (NPI 1598581647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598581647 NPI number — CLEAN SLATE ADULT FAMILY HOME CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAN SLATE ADULT FAMILY HOME CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598581647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5743 N 77TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53218-2144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-234-4783
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5102 N 77TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53218-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-616-1668
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SIMMON
Authorized Official First Name:
TYRONE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
630-234-4783

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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