Basic Information
| Provider Information | |||||||||
| NPI: | 1225205800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND HEALTH VENTURES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLOVER FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601544 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032220600 | ||||||||
| FaxNumber: | 8032226119 | ||||||||
| Practice Location | |||||||||
| Address1: | 3420 FILBERT HWY | ||||||||
| Address2: | |||||||||
| City: | CLOVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297105602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032220600 | ||||||||
| FaxNumber: | 8032226119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIENS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7043550648 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEVELAND HEALTH VENTURES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4970 | 05 | SC | MEDICAID |