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General NPI Number Information
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NPI Number | 1942728472
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Entity Type | Organization
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Legal Business Name | CLEANSE CLINIC JEFFERSONVILLE LLC
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Dates
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Enumeration Date | 09/05/2017
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Last Update Date | 01/31/2024
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Provider Practice Location Address
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Address Line | 1700 STATE ST
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City | NEW ALBANY
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State | IN
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Zip | 47150-4916
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Country | US
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Telephone | 812-914-7038
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Fax | 812-748-6035
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Provider Business Mailing Address
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Address Line | 720 W BROADWAY STE 202
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City | LOUISVILLE
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State | KY
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Zip | 40202-3245
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Country | US
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Telephone | 502-561-0943
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Fax | 502-561-0944
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Authorized Official
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Title or Position | CEO
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Name | ABDUL G BURIDI
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Credential | MD
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Telephone | 502-773-5088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | 1784-0-ASO
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License Number State | IN
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