Provider Demographics
NPI:1225205800
Name:CLEVELAND HEALTH VENTURES LLC
Entity Type:Organization
Organization Name:CLEVELAND HEALTH VENTURES LLC
Other - Org Name:CLOVER FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 601544
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1544
Mailing Address - Country:US
Mailing Address - Phone:803-222-0600
Mailing Address - Fax:803-222-6119
Practice Address - Street 1:3420 FILBERT HWY
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-5602
Practice Address - Country:US
Practice Address - Phone:803-222-0600
Practice Address - Fax:803-222-6119
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND HEALTH VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-13
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4970Medicaid