Provider Demographics
NPI:1942728472
Name:CLEANSE CLINIC JEFFERSONVILLE LLC
Entity Type:Organization
Organization Name:CLEANSE CLINIC JEFFERSONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-773-5088
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 1:1700 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4916
Practice Address - Country:US
Practice Address - Phone:812-914-7038
Practice Address - Fax:812-748-6035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEANSE CLINIC CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-05
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1784-0-ASO2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300008912Medicaid