Provider Demographics
NPI:1295333052
Name:CLEAN SLATE SOBER LIVING, LLC
Entity type:Organization
Organization Name:CLEAN SLATE SOBER LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:FANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-548-7627
Mailing Address - Street 1:714 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2909
Mailing Address - Country:US
Mailing Address - Phone:184-454-8762
Mailing Address - Fax:
Practice Address - Street 1:714 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2909
Practice Address - Country:US
Practice Address - Phone:844-548-7627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)