Healthcare Provider Details

I. General information

NPI: 1194311639
Provider Name (Legal Business Name): CLEAN COUNTRY LIVIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27158 TRITON DR
SPRING BRANCH TX
78070-5043
US

IV. Provider business mailing address

27158 TRITON DR
SPRING BRANCH TX
78070-5043
US

V. Phone/Fax

Practice location:
  • Phone: 830-387-2065
  • Fax:
Mailing address:
  • Phone: 830-387-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA BLACK
Title or Position: DIRECTOR OF BILLING AND INSURANCE
Credential:
Phone: 830-387-2065