Provider Demographics
NPI:1609226364
Name:CLEAN COLONIC LLC
Entity Type:Organization
Organization Name:CLEAN COLONIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COLON HYDROTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-269-5575
Mailing Address - Street 1:7560 S WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-5004
Mailing Address - Country:US
Mailing Address - Phone:480-269-5575
Mailing Address - Fax:
Practice Address - Street 1:7560 S. WILLOW DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283
Practice Address - Country:US
Practice Address - Phone:952-994-3554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251K00000XAgenciesPublic Health or Welfare