=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801421656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2020
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15255 N 40TH ST STE 135
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-4682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-417-4215
-----------------------------------------------------
Fax | 833-279-7074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 CADILLAC DR STE 300
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-425-0220
-----------------------------------------------------
Fax | 833-279-7074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MATTHEW PHILIP SMOLAREK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-999-5188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------