NPIMap

Organization Active NPI

Clean Slate Adult Family Home Corp.

  • Adult Care Home Facility
  • Milwaukee, WI
National Provider Identifier
1497571541
Registry record updated Nov 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adult Care Home FacilityTaxonomy code 311ZA0620X
Legal business name
CLEAN SLATE ADULT FAMILY HOME CORP.
Practice address
5100 N 77TH St
Milwaukee, WI 53218-3701
Phone
(414) 616-1868
NPI assigned
Nov 22, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tyrone Simmon
Title
Owner
Phone
(630) 234-4783

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Care Home Facility 311ZA0620X Primary

Addresses

Primary practice location

5100 N 77TH St
Milwaukee, WI 53218-3701

Mailing address

5743 N 77TH St
Milwaukee, WI 53218-2144
Phone (630) 234-4783

National Provider Directory

National Provider Directory
Tax ID family
Clean Slate Adult Family Home Corp4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1732233600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732233600000",
    "number": "1497571541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5743 N 77TH ST",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532182144",
            "telephone_number": "630-234-4783"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5100 N 77TH ST",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532183701",
            "telephone_number": "414-616-1868"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLEAN SLATE ADULT FAMILY HOME CORP.",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-11-22",
        "last_updated": "2024-11-22",
        "certification_date": "2024-11-22",
        "status": "A",
        "authorized_official_last_name": "SIMMON",
        "authorized_official_first_name": "TYRONE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "630-234-4783"
    },
    "taxonomies": [
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Milwaukee, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.