Provider Demographics
NPI:1447585542
Name:CLEVELAND HEALTH VENTURES LLC
Entity Type:Organization
Organization Name:CLEVELAND HEALTH VENTURES LLC
Other - Org Name:KINGS MOUNTAIN INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. 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 601884
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1884
Mailing Address - Country:US
Mailing Address - Phone:980-487-2290
Mailing Address - Fax:704-730-8472
Practice Address - Street 1:502 W KING ST
Practice Address - Street 2:SUITE A
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3362
Practice Address - Country:US
Practice Address - Phone:980-487-2290
Practice Address - Fax:704-730-8472
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND HEALTH VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-07
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB348Medicaid
NC5914428Medicaid
NC2335645FMedicare PIN