Healthcare Provider Details

I. General information

NPI: 1306774500
Provider Name (Legal Business Name): CLEVELAND MEDICAL MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 BLOSSOM CENTRE BLVD STE 105
WILLARD OH
44890-9317
US

IV. Provider business mailing address

117 BLOSSOM CENTRE BLVD STE 105
WILLARD OH
44890-9317
US

V. Phone/Fax

Practice location:
  • Phone: 419-561-4552
  • Fax: 513-712-4573
Mailing address:
  • Phone: 419-561-4552
  • Fax: 513-712-4573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CORBY JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 800-423-6078