Healthcare Provider Details

I. General information

NPI: 1376178129
Provider Name (Legal Business Name): CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 E BASELINE RD STE 430
GILBERT AZ
85234-2473
US

IV. Provider business mailing address

8 CADILLAC DR STE 300
BRENTWOOD TN
37027-5337
US

V. Phone/Fax

Practice location:
  • Phone: 602-313-4391
  • Fax: 833-279-7074
Mailing address:
  • Phone: 615-425-0220
  • Fax: 833-279-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW PHILIP SMOLAREK
Title or Position: CFO
Credential:
Phone: 412-999-5188