Provider Demographics
NPI:1598830408
Name:CLEVELAND HEALTH VENTURES, LLC
Entity Type:Organization
Organization Name:CLEVELAND HEALTH VENTURES, LLC
Other - Org Name:SHELBY CHILDREN'S CLINIC
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 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:980-487-2100
Mailing Address - Fax:704-482-8779
Practice Address - Street 1:709 N DEKALB ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3911
Practice Address - Country:US
Practice Address - Phone:980-487-2100
Practice Address - Fax:704-482-8779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND HEALTH VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905769Medicaid
NC5905487Medicaid
NC6006026Medicaid