Provider Demographics
NPI:1073814679
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
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
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:980-487-5510
Mailing Address - Fax:980-487-5515
Practice Address - Street 1:706 W. KINGS STREET
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2708
Practice Address - Country:US
Practice Address - Phone:980-487-5510
Practice Address - Fax:980-487-5515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEVELAND HEALTH VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-12
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916702Medicaid
SCNPB422Medicaid
SCNPB422Medicaid