1801421656 NPI number — CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC

Table of content: (NPI 1801421656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801421656 NPI number — CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC
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:
CLEANSLATE CENTERS- NORTH 40TH PHOENIX, AZ.
Provider Other Organization Name Type Code:
3
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:
1801421656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 CADILLAC DR STE 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-425-0220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15255 N 40TH ST STE 135
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85032-4682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-417-4215
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2020

Additional Information

Authorized Official

Authorized Official Last Name:
AMICK
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
AO
Authorized Official Telephone Number:
727-798-8160

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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