# CLEAN SLATE ADULT FAMILY HOME CORP.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104681238
- **Authorized official:** TYRONE SIMMONS (OWNER)
- **Authorized official phone:** (630) 234-4783

## Contact information

- **Practice address:** 5743 N 77TH ST, MILWAUKEE, WI 53218-2144
- **Practice address phone:** (262) 804-0099
- **Mailing address:** 5743 N 77TH ST, MILWAUKEE, WI 53218-2144
- **Mailing address phone:** (262) 804-0099

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 311ZA0620X | Adult Care Home Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 02/19/2024
- **Last updated:** 11/22/2024