MEDICARE: PRISTINE RESIDENTIAL CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251C00000X	Developmentally Disabled Services Day Training Agency
3	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
4	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
5	343800000X	Secured Medical Transport (VAN)
6	343900000X	Non-emergency Medical Transport (VAN)
7	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1699499798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISTINE RESIDENTIAL CARE

Provider Business Mailing Address
First Line	:	709 LODGE AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-2915
Country	:	US
Telephone Number	:	567-702-1078
Fax Number	:

Provider Business Practice Location Address
First Line	:	709 LODGE AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-2915
Country	:	US
Telephone Number	:	567-702-1078
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DEMETRIA CLARK
Credential	:
Telephone Number	:	567-702-1078

Provider Enumeration Date	:	10/03/2022
Last Update Date	:	10/03/2022

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Directions to “PRISTINE RESIDENTIAL CARE ” Practice Location

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