Healthcare Provider Details

I. General information

NPI: 1760760052
Provider Name (Legal Business Name): CLEVELAND HEALTH VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E. KING STREET
KINGS MOUNTAIN NC
28086-3186
US

IV. Provider business mailing address

PO BOX 601884
CHARLOTTE NC
28260-1884
US

V. Phone/Fax

Practice location:
  • Phone: 704-650-6551
  • Fax: 704-512-4808
Mailing address:
  • Phone: 704-650-6551
  • Fax: 704-512-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL J. WIENS
Title or Position: VICE-PRESIDENT OF OPERATIONS
Credential:
Phone: 704-667-0410