Provider Demographics
NPI:1740616820
Name:CLEVELAND CLINIC SPORTS HEALTH CENTER
Entity Type:Organization
Organization Name:CLEVELAND CLINIC SPORTS HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR OF AT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-518-3429
Mailing Address - Street 1:4683 WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-9664
Mailing Address - Country:US
Mailing Address - Phone:330-274-8396
Mailing Address - Fax:
Practice Address - Street 1:4683 WAYNE ROAD
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255
Practice Address - Country:US
Practice Address - Phone:330-274-8396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CLEVELAND CLINIC FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT. 004124261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation