Healthcare Provider Details

I. General information

NPI: 1255317145
Provider Name (Legal Business Name): CLEAN & SOBER DETOX A CALIFORNIA NONPROFIT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8946 MADISON AVE
FAIR OAKS CA
95628
US

IV. Provider business mailing address

3 CORBETT WAY
EATONTOWN NJ
07724-2283
US

V. Phone/Fax

Practice location:
  • Phone: 916-965-3386
  • Fax: 916-536-1393
Mailing address:
  • Phone: 973-901-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number340067AN
License Number StateCA

VIII. Authorized Official

Name: MARYL RUSSO
Title or Position: FACILITIES ADMIN
Credential:
Phone: 916-273-4537