Provider Demographics
NPI:1497096960
Name:CLEAN IMAGE
Entity Type:Organization
Organization Name:CLEAN IMAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MLS
Authorized Official - Phone:413-464-7521
Mailing Address - Street 1:10 WENDELL AVENUE EXT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6283
Mailing Address - Country:US
Mailing Address - Phone:413-464-7521
Mailing Address - Fax:877-208-8430
Practice Address - Street 1:10 WENDELL AVENUE EXT
Practice Address - Street 2:SUITE 105
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6283
Practice Address - Country:US
Practice Address - Phone:413-464-7521
Practice Address - Fax:877-208-8430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22D2047480291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory