=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669297560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEAN INVESTMENTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4710 N MAPLE GROVE RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-376-9744
-----------------------------------------------------
Fax | 208-545-7917
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4710 N MAPLE GROVE RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-376-9744
-----------------------------------------------------
Fax | 208-545-7917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RYAN YORK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-376-9744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0800X
-----------------------------------------------------
Taxonomy Name | Recovery Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------