Provider Demographics
NPI:1265826077
Name:MCCLEVE, JOHN MIRAM IV
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MIRAM
Last Name:MCCLEVE
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7679 BLUE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49457-9408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7679 BLUE LAKE RD
Practice Address - Street 2:
Practice Address - City:TWIN LAKE
Practice Address - State:MI
Practice Address - Zip Code:49457
Practice Address - Country:US
Practice Address - Phone:616-490-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer