Provider Demographics
NPI:1356876767
Name:CLEAR DETOX CENTER INC.
Entity type:Organization
Organization Name:CLEAR DETOX CENTER INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:NERSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-200-7555
Mailing Address - Street 1:546 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2617
Mailing Address - Country:US
Mailing Address - Phone:949-200-7555
Mailing Address - Fax:949-548-0804
Practice Address - Street 1:552 HAMILTON ST
Practice Address - Street 2:UNIT E1
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5570
Practice Address - Country:US
Practice Address - Phone:949-200-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300372AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility