CLEANSLATE MEDICAL GROUP OF VIRGINIA, LLC (NPI# 1629549779) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1629549779 |
| Entity Type | Organization |
| Organization Name | CLEANSLATE MEDICAL GROUP OF VIRGINIA, LLC |
| Practice Address |
160 Kingsley Ln Ste 303 Norfolk VA 23505-4600 |
| Mailing Address |
12 Cadillac Dr Ste 380 Brentwood TN 37027-5272 |
| Practice Telephone | 4135842173 |
| Enumeration Date | 2018-12-16 |
| Last Update Date | 2019-07-02 |
| Authorized Official Name | ROBERT HUTCHISON (CFO) |
| Authorized Official Telephone | 6154250220 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207R00000X | Internal Medicine | Allopathic & Osteopathic Physicians | ||
| Y | 207RA0401X |
Internal Medicine Specialization: Addiction Medicine |
Allopathic & Osteopathic Physicians |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 15 Century Blvd Ste 307, Nashville, TN 372143692 | 6154250220 |
| Street Address |
160 KINGSLEY LN STE 303 |
| City | NORFOLK |
| State | VA |
| Zip Code | 23505-4600 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1154844256 | Cassandra Shelton | Specialist/Technologist, Other | 100 Kingsley Lane, Norfolk, VA 23505 | 2017-07-20 |
| 1063942852 | Gabriela Marie Santiago | Specialist/Technologist | 7600 Victory Dr, Apt 3, Norfolk, VA 23505 | 2017-06-14 |
| 1144776725 | Amr Hassan | Pharmacist | 1610 W Little Creek Rd, Apt 204, Norfolk, VA 23505 | 2016-09-01 |
| 1992175095 | Heather Mitchell | Nurse Practitioner | 110 Kingsley Ln Ste 309, Norfolk, VA 23505 | 2015-10-01 |
| 1255710620 | Jessica Ann Kestranek | Dentist | 7400 Granby St Ste D, Norfolk, VA 23505 | 2015-05-19 |
| 1710375274 | Carla Toledo | Nurse Practitioner | 155 Kingsley Lane, Suite 400, Norfolk, VA 23505 | 2015-01-06 |
| 1417359746 | James Austin Valone Jr. | Ophthalmology | 1423 Runymede Rd, Norfolk, VA 23505 | 2014-09-18 |
| 1861813370 | Harris Teeter, LLC | Pharmacy | 7550 Granby Street, Norfolk, VA 23505 | 2013-12-31 |
| 1649549361 | Linda Horsey | Social Worker | 7510 Granby Street, Suite 6, Norfolk, VA 23505 | 2011-12-27 |
| 1679705164 | Carolyn Lee Kee | Nurse's Aide | 7403 Hampton Blvd, Norfolk, VA 23505 | 2009-08-17 |
| Find all providers in zip 23505 | ||||
| Taxonomy Code | 207RA0401X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Internal Medicine |
| Specialization | Addiction Medicine |
| An internist doctor of osteopathy that specializes in the treatment of addiction disorders. A doctor of osteopathy that is board eligible/certified by the American Osteopathic Board of Internal Medicine can obtain a Certificate of Added Qualifications in the field of Addiction Medicine. |
| Notes: Source: American Osteopathic Board of Internal Medicine, 2007. [7/1/2008: added definition, added source; 7/1/2011: modified source] - Additional Resources: http://www.osteopathic.org/certification |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1790304616 | Mind Bridge Center LLC | Internal Medicine | 1390 Chain Bridge Rd # 10033, Mc Lean, VA 22101-3904 | 2020-04-10 |
| 1053945428 | Radical Recovery Treatment Center Inc | Internal Medicine | 5040 Virginia Beach Blvd Ste 104, Virginia Beach, VA 23462-6637 | 2020-02-25 |
| 1245789460 | Nova Addiction Specialists Lllc | Internal Medicine | 101 N Columbus St, Suite 405, Alexandria, VA 22314-3056 | 2016-09-29 |
| 1184791725 | Alta J. Deroo | Internal Medicine | 767 Madison Rd Ste 107, Culpeper, VA 22701 | 2006-11-29 |
| 1881639375 | Sergey Zhitar | Internal Medicine | 101 N Lynnhaven Rd, Suite 100, Virginia Beach, VA 23452-7523 | 2006-06-18 |
| 1295724888 | Farook A. Shaikh | Internal Medicine | 6305 Castle Pl, Suite 3c, Falls Church, VA 22044-1905 | 2005-10-17 |
| 1992790406 | Jann L Holwick | Internal Medicine | 2609 Sheffield Dr Ste 100, Blacksburg, VA 24060-8271 | 2005-09-12 |
| 1972120483 | Global Health Services | Internal Medicine | 6395 Little River Tpke, Alexandria, VA 22312-5003 | 2020-06-30 |
| 1932554953 | Lotus Health, LLC | Internal Medicine | 2300 Dumbarton Rd, Richmond, VA 23228-6014 | 2016-04-27 |
| 1669858635 | Legacy Health Management Solutions | Internal Medicine | 5206 Markel Rd, Suite 102, Richmond, VA 23230-3044 | 2015-07-31 |
| Find all providers with the same taxonomy | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.