Basic Information
| Provider Information | |||||||||
| NPI: | 1104334226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CLEVELAND CLINIC FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLEVELAND CLINC COLE EYE - AVON LAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 BRECKSVILLE RD | ||||||||
| Address2: | SUITE 20, RK2-7 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441315062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166364969 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 AVON BELDEN RD | ||||||||
| Address2: | |||||||||
| City: | AVON LAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440122282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409338300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2018 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDVE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2169733321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 332H00000X | OH | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.