MEDICARE: CLEVELAND HEALTH VENTURES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396070652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND HEALTH VENTURES LLC

Provider Business Mailing Address
First Line	:	PO BOX 602341
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2341
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 W KING ST
Second Line	:	SUITE B
City	:	KINGS MOUNTAIN
State	:	NC
Zip	:	28086-3362
Country	:	US
Telephone Number	:	980-487-2299
Fax Number	:	704-730-8262

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	MR. DANIEL WIENS
Credential	:
Telephone Number	:	704-355-0648

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	06/28/2010

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Directions to “CLEVELAND HEALTH VENTURES LLC ” Practice Location

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