Provider Demographics
NPI:1093178337
Name:CLEVELAND CHILDREN'S CLINIC, PLLC
Entity Type:Organization
Organization Name:CLEVELAND CHILDREN'S CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREVIL
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:662-579-3449
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-0060
Mailing Address - Country:US
Mailing Address - Phone:662-579-3449
Mailing Address - Fax:662-579-3469
Practice Address - Street 1:818 E SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2824
Practice Address - Country:US
Practice Address - Phone:662-579-3449
Practice Address - Fax:662-579-3459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23162208000000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00325056Medicaid