MEDICARE: CLEAN SLATE LIVING

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	291U00000X	Clinical Medical Laboratory	10D2063192	FL

General Provider Information

NPI Number	:	1265860522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAN SLATE LIVING

Provider Business Mailing Address
First Line	:	118 CANOE DR
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-2602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 CANOE DR
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-2602
Country	:	US
Telephone Number	:	561-270-2361
Fax Number	:

Authorized Official
Title or Position	:	BILLING DIRECTOR
Name	:	ANGELA IACULLO
Credential	:
Telephone Number	:	561-270-2361

Provider Enumeration Date	:	10/24/2013
Last Update Date	:	10/24/2013

Similar Medicare Providers

1497832083 — DR. LYSA CHARLES MD
Practice Location Address:

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308

1326426339 — NOZZLE NOLEN, INC
Practice Location Address:

5400 BROADWAY
WEST PALM BEACH, FL
33407-2602

Practice Phone: 561-844-3544
Practice Fax:

1689108748 — DR. LUAN DINH PHAM PHARMD
Practice Location Address:

454 PARK AVE
WEST PALM BEACH, FL
33403-2602

Practice Phone: 561-685-3530
Practice Fax:

1114048675 — HARBORSIDE REHABILITATION LP
Practice Location Address:

2602 HIGHLANDS BLVD N
PALM HARBOR, FL
34684-2114

Practice Phone: 800-276-4556
Practice Fax: 727-786-6265

1720224074 — NICOLE T GORDON, DMD, PLC
Practice Location Address:

691 ALDERMAN RD
PALM HARBOR, FL
34683-2602

Practice Phone: 727-724-4227
Practice Fax:

1013283944 — MRS. AMY A. SANTOS OTR/L
Practice Location Address:

2125 GRANVILLE ST NE
PALM BAY, FL
32907-2602

Practice Phone: 413-841-3607
Practice Fax:

Directions to “CLEAN SLATE LIVING ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.