Healthcare Provider Details

I. General information

NPI: 1942728472
Provider Name (Legal Business Name): CLEANSE CLINIC JEFFERSONVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 STATE ST
NEW ALBANY IN
47150-4916
US

IV. Provider business mailing address

720 W BROADWAY STE 202
LOUISVILLE KY
40202-3245
US

V. Phone/Fax

Practice location:
  • Phone: 812-914-7038
  • Fax: 812-748-6035
Mailing address:
  • Phone: 502-561-0943
  • Fax: 502-561-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number1784-0-ASO
License Number StateIN

VIII. Authorized Official

Name: ABDUL G BURIDI
Title or Position: CEO
Credential: MD
Phone: 502-773-5088