Provider Demographics
NPI:1780460642
Name:CLEVELAND CHILDREN'S CLINIC, PLLC
Entity type:Organization
Organization Name:CLEVELAND CHILDREN'S CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREVIL
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:662-579-3449
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-0060
Mailing Address - Country:US
Mailing Address - Phone:662-579-3449
Mailing Address - Fax:
Practice Address - Street 1:1431 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7243
Practice Address - Country:US
Practice Address - Phone:662-579-3449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty