Provider Demographics
NPI:1629549779
Name:CLEANSLATE MEDICAL GROUP OF VIRGINIA, LLC
Entity Type:Organization
Organization Name:CLEANSLATE MEDICAL GROUP OF VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTCHISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-425-0220
Mailing Address - Street 1:12 CADILLAC DR STE 380
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 KINGSLEY LN STE 303
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4600
Practice Address - Country:US
Practice Address - Phone:413-584-2173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty