Provider Demographics
NPI:1861967002
Name:KLEAN LIFE DETOX
Entity type:Organization
Organization Name:KLEAN LIFE DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KASALI
Authorized Official - Middle Name:
Authorized Official - Last Name:OPABOLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:561-634-6400
Mailing Address - Street 1:7135 VIA ABRUZZI
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 E BLUE HERON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-4560
Practice Address - Country:US
Practice Address - Phone:561-634-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder