MEDICARE: CLEAN TREATMENT CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1174109128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAN TREATMENT CENTER, INC.

Provider Business Mailing Address
First Line	:	123 HODENCAMP RD STE 205
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-5834
Country	:	US
Telephone Number	:	818-436-2231
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 HODENCAMP RD STE 205
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-5834
Country	:	US
Telephone Number	:	213-700-6050
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	IRENE BRIDGETT HYDER
Credential	:
Telephone Number	:	213-700-6050

Provider Enumeration Date	:	03/21/2021
Last Update Date	:	06/03/2025

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