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General NPI Number Information
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NPI Number | 1609226364
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Entity Type | Organization
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Legal Business Name | CLEAN COLONIC LLC
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Dates
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Enumeration Date | 06/14/2016
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Last Update Date | 01/19/2017
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Provider Practice Location Address
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Address Line | 7560 S. WILLOW DR
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City | TEMPE
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State | AZ
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Zip | 85283
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Country | US
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Telephone | 952-994-3554
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Fax |
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Provider Business Mailing Address
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Address Line | 7560 S WILLOW DR
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City | TEMPE
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State | AZ
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Zip | 85283-5004
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Country | US
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Telephone | 480-269-5575
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Fax |
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Authorized Official
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Title or Position | COLON HYDROTHERAPIST
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Name | CAROLYN DEE BERRY
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Credential |
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Telephone | 480-269-5575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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