Provider Demographics
NPI:1255585899
Name:CLEVELAND HEALTH VENTURES
Entity type:Organization
Organization Name:CLEVELAND HEALTH VENTURES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
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:828-245-3158
Mailing Address - Fax:828-247-6484
Practice Address - Street 1:249 OAK ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3585
Practice Address - Country:US
Practice Address - Phone:828-245-3158
Practice Address - Fax:828-247-6484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND HEALTH VENTURES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-10
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913096Medicaid
NC7004416Medicaid
NC5913096Medicaid