Provider Demographics
NPI:1659726628
Name:CLEANSE CLINIC, PSC
Entity Type:Organization
Organization Name:CLEANSE CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:GROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-987-4330
Mailing Address - Street 1:720 W BROADWAY STE 202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3245
Mailing Address - Country:US
Mailing Address - Phone:502-561-0943
Mailing Address - Fax:502-561-0944
Practice Address - Street 1:645 S ROY WILKINS AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2072
Practice Address - Country:US
Practice Address - Phone:502-583-4092
Practice Address - Fax:502-371-6110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8002122084P0802X
KY8104932084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100413630Medicaid