Provider Demographics
NPI:1427874569
Name:CLEAN SLATE ADULT FAMILY HOME CORP.
Entity type:Organization
Organization Name:CLEAN SLATE ADULT FAMILY HOME CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SIMMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-234-4783
Mailing Address - Street 1:5743 N 77TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-2144
Mailing Address - Country:US
Mailing Address - Phone:630-234-4783
Mailing Address - Fax:
Practice Address - Street 1:6918 W BIRCH CT
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2955
Practice Address - Country:US
Practice Address - Phone:414-231-3108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home