Basic Information
| Provider Information | |||||||||
| NPI: | 1780987693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEVELAND HEALTH VENTURES LLC | ||||||||
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| OtherOrganizationName: | CHV SHVI SHELBY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601884 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044821006 | ||||||||
| FaxNumber: | 7044848855 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W. GROVER STREET | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044821006 | ||||||||
| FaxNumber: | 7044848855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | WIENS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| 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 | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | NPB416 | 05 | SC | MEDICAID | 5917581 | 05 | NC | MEDICAID |