Basic Information
Provider Information
NPI: 1700987856
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLEVEN
FirstName: CHAD
MiddleName: J.
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 20200 54TH AVE W
Address2:  
City: LYNNWOOD
State: WA
PostalCode: 980366318
CountryCode: US
TelephoneNumber: 4256726400
FaxNumber: 4256726518
Practice Location
Address1: 20200 54TH AVE W
Address2:  
City: LYNNWOOD
State: WA
PostalCode: 980366318
CountryCode: US
TelephoneNumber: 4256726400
FaxNumber: 4256726518
Other Information
ProviderEnumerationDate: 09/25/2006
LastUpdateDate: 11/17/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/17/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XOP00001982WAY Allopathic & Osteopathic PhysiciansInternal Medicine 
207RA0000XOP00001982WAN Allopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine

ID Information
IDTypeStateIssuerDescription
709541705WA MEDICAID


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