Healthcare Provider Details

I. General information

NPI: 1568458925
Provider Name (Legal Business Name): THE CLEVELAND CLINIC FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 PARK AVE W
MANSFIELD OH
44906-3118
US

IV. Provider business mailing address

6801 BRECKSVILLE RD STE 20
INDEPENDENCE OH
44131-5062
US

V. Phone/Fax

Practice location:
  • Phone: 419-525-0330
  • Fax: 419-994-2612
Mailing address:
  • Phone: 216-636-4969
  • Fax: 216-442-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY L. LONGVILLE
Title or Position: CHIEF ACCT OFFICER AND CONTROLLER
Credential:
Phone: 216-636-7416