Provider Demographics
NPI:1376178129
Name:CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC
Entity Type:Organization
Organization Name:CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC
Other - Org Name:CLEANSLATE CENTERS- GILBERT, AZ.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-798-8160
Mailing Address - Street 1:8 CADILLAC DR STE 180
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5393
Mailing Address - Country:US
Mailing Address - Phone:615-425-0220
Mailing Address - Fax:
Practice Address - Street 1:2451 E BASELINE RD STE 430
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2473
Practice Address - Country:US
Practice Address - Phone:602-313-4391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-11
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health