Basic Information
| Provider Information | |||||||||
| NPI: | 1245865096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC | ||||||||
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| OtherOrganizationName: | CLEANSLATE CENTERS- WEST THOMAS PHOENIX, AZ | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 8410 W THOMAS RD STE 124 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850373373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804175289 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | AMICK | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AO | ||||||||
| AuthorizedOfficialTelephone: | 7277988160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.