Provider Demographics
NPI:1063439966
Name:CLEVELAND VA CBOC
Entity type:Organization
Organization Name:CLEVELAND VA CBOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HIBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-693-5600
Mailing Address - Street 1:631 MARK AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-1721
Mailing Address - Country:US
Mailing Address - Phone:920-467-6079
Mailing Address - Fax:
Practice Address - Street 1:1205 NORTH AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:WI
Practice Address - Zip Code:53015-1413
Practice Address - Country:US
Practice Address - Phone:188-846-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18107-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty