Provider Demographics
NPI:1255317145
Name:CLEAN & SOBER DETOX A CALIFORNIA NONPROFIT CORPORATION
Entity Type:Organization
Organization Name:CLEAN & SOBER DETOX A CALIFORNIA NONPROFIT CORPORATION
Other - Org Name:CLEAN & SOBER DETOX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FACILITIES ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-273-4537
Mailing Address - Street 1:3 CORBETT WAY
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-2283
Mailing Address - Country:US
Mailing Address - Phone:973-901-6123
Mailing Address - Fax:
Practice Address - Street 1:8946 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628
Practice Address - Country:US
Practice Address - Phone:916-965-3386
Practice Address - Fax:916-536-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340067AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherOTHER