MEDICARE: CLEAN SHOT 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1407663115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAN SHOT LIVING

Provider Business Mailing Address
First Line	:	1813 BETTY LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-6728
Country	:	US
Telephone Number	:	877-457-6238
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 BETTY LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-6728
Country	:	US
Telephone Number	:	877-457-6238
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS ZARRO
Credential	:
Telephone Number	:	702-287-9715

Provider Enumeration Date	:	12/16/2024
Last Update Date	:	12/16/2024

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Directions to “CLEAN SHOT LIVING ” Practice Location

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