Provider Demographics
NPI:1649345935
Name:CLEVELAND HEALTH VENTURES LLC
Entity type:Organization
Organization Name:CLEVELAND HEALTH VENTURES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF OPERATIONS
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:980-487-1148
Mailing Address - Fax:704-487-7753
Practice Address - Street 1:1124 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3862
Practice Address - Country:US
Practice Address - Phone:980-487-1148
Practice Address - Fax:704-487-7753
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND HEALTH VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905818Medicaid
SCNPB304Medicaid
SCNPB304Medicaid