Basic Information
| Provider Information | |||||||||
| NPI: | 1659726628 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEANSE CLINIC, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W BROADWAY STE 202 | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025610943 | ||||||||
| FaxNumber: | 5025610944 | ||||||||
| Practice Location | |||||||||
| Address1: | 9720 PARK PLAZA AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402412288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029380511 | ||||||||
| FaxNumber: | 5023716110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2016 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | GROLL | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5025610943 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | 800212 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7100413630 | 05 | KY | MEDICAID |