| Cleanse Clinic, Pllc | |
|
645 S Roy Wilkins Ave Ste 100 Louisville KY 40203-2072 | |
| (502) 583-4092 | |
| (502) 371-6110 |
| Full Name | Cleanse Clinic, Pllc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 645 S Roy Wilkins Ave Ste 100, Louisville, Kentucky |
| Authorized Official Name and Position | Margaret Groll (BUSINESS MANAGER) |
| Authorized Official Contact | 8129874330 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Cleanse Clinic, Pllc 720 W Broadway Ste 202 Louisville KY 40202-3245 Ph: (502) 561-0943 | Cleanse Clinic, Pllc 645 S Roy Wilkins Ave Ste 100 Louisville KY 40203-2072 Ph: (502) 583-4092 |
| NPI Number | 1659726628 |
|---|---|
| Provider Enumeration Date | 04/27/2016 |
| Last Update Date | 08/13/2024 |
| Certification Date | 08/13/2024 |
| Medicare PECOS PAC ID | 1759630320 |
|---|---|
| Medicare Enrollment ID | O20241011003387 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659726628 | NPI | - | NPPES |
| 7100413630 | Medicaid | KY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0802X | Psychiatry & Neurology - Addiction Psychiatry | 800212 (Kentucky) | Primary |
| Provider Name | Syed Q Kazmi |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1487619888 PECOS PAC ID: 2567367790 Enrollment ID: I20040326000022 |
| Provider Name | Asad Ismail |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1144227026 PECOS PAC ID: 7214926195 Enrollment ID: I20040506001422 |
| Provider Name | Sarah Ann Thomas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629445705 PECOS PAC ID: 4486962693 Enrollment ID: I20210628000136 |
| Provider Name | Janessa Marie James |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1275388696 PECOS PAC ID: 9537603329 Enrollment ID: I20241016001228 |
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