Basic Information
| Provider Information | |||||||||
| NPI: | 1942728472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEANSE CLINIC JEFFERSONVILLE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W BROADWAY STE 202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025610943 | ||||||||
| FaxNumber: | 5025610944 | ||||||||
| Practice Location | |||||||||
| Address1: | 2818 GRANT LINE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129147038 | ||||||||
| FaxNumber: | 8129247661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | BURIDI | ||||||||
| AuthorizedOfficialFirstName: | ABDUL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5027735088 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEANSE CLINIC CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | 1784-0-ASO | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 300008912 | 05 | IN | MEDICAID |