Basic Information
| Provider Information | |||||||||
| NPI: | 1184177263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEANSLATE MEDICAL GROUP OF PENNSYLVANIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 CADILLAC DR STE 380 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154250220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N WILKES BARRE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187025240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135842173 | ||||||||
| FaxNumber: | 4137273619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | AMICK | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7277988160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.