MEDICARE: JUST LIVE CLEAN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0301X	Brain Injury Medicine (Psychiatry & Neurology) Physician

General Provider Information

NPI Number	:	1851075881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUST LIVE CLEAN

Provider Business Mailing Address
First Line	:	3245 RED SCOTT CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3255
Country	:	US
Telephone Number	:	725-500-0400
Fax Number	:	702-323-6251

Provider Business Practice Location Address
First Line	:	4270 S DECATUR BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-6800
Country	:	US
Telephone Number	:	725-500-0400
Fax Number	:	702-323-6251

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. JAMIE LEE CICHON
Credential	:	MD
Telephone Number	:	725-500-0400

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	06/12/2023

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Directions to “JUST LIVE CLEAN ” Practice Location

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