=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427874569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEAN SLATE ADULT FAMILY HOME CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2024
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6918 W BIRCH CT
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53218-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-231-3108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5743 N 77TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53218-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-234-4783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TYRONE D SIMMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-234-4783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------