Provider Demographics
NPI:1194311639
Name:CLEAN COUNTRY LIVIN LLC
Entity type:Organization
Organization Name:CLEAN COUNTRY LIVIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING AND INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-387-2065
Mailing Address - Street 1:27158 TRITON DR
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-5043
Mailing Address - Country:US
Mailing Address - Phone:830-387-2065
Mailing Address - Fax:
Practice Address - Street 1:27158 TRITON DR
Practice Address - Street 2:
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-5043
Practice Address - Country:US
Practice Address - Phone:830-387-2065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging