Healthcare Provider Details

I. General information

NPI: 1235515446
Provider Name (Legal Business Name): CLEVELAND FAMILY HEALTH CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 SHIPWASH DRIVE
GARNER NC
27529
US

IV. Provider business mailing address

22 SHIPWASH DR
GARNER NC
27529-6861
US

V. Phone/Fax

Practice location:
  • Phone: 919-662-7600
  • Fax: 919-662-7675
Mailing address:
  • Phone: 919-662-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011-00283
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01664
License Number StateNC

VIII. Authorized Official

Name: MARIAN J. BULLARD
Title or Position: OWNER
Credential: P.A. C
Phone: 919-662-7600