# CLEANSLATE MEDICAL GROUP OF VIRGINIA, LLC

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

## Provider details

- **NPI number:** 1629549779
- **Authorized official:** MATTHEW PHILIP SMOLAREK (CFO)
- **Authorized official phone:** (412) 999-5188

## Contact information

- **Practice address:** 8220 MEADOWBRIDGE RD STE 310, MECHANICSVILLE, VA 23116-2340
- **Practice address phone:** (804) 417-0120
- **Practice address fax:** (804) 277-3029
- **Mailing address:** 8 CADILLAC DR STE 180, BRENTWOOD, TN 37027-5393
- **Mailing address phone:** (615) 425-0220

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207RA0401X | Addiction Medicine (Internal Medicine) Physician | — | NULL | Yes |
| 207RA0401X | Addiction Medicine (Internal Medicine) Physician | — | — | Yes |

## Other

- **Enumeration date:** 12/16/2018
- **Last updated:** 07/03/2024