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General NPI Number Information
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NPI Number | 1154337558
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Entity Type | Organization
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Legal Business Name | CLEVELAND VA CBOC
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Dates
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Enumeration Date | 07/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1205 NORTH AVE
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City | CLEVELAND
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State | WI
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Zip | 53015-1413
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Country | US
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Telephone | 188-469-6614
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Fax |
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Provider Business Mailing Address
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Address Line | 336 E JEFFERSON AVE
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City | CLEVELAND
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State | WI
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Zip | 53015-1530
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Country | US
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Telephone | 920-693-8478
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Fax |
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Authorized Official
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Title or Position | LPN
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Name | AGNES E. DEEHR
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Credential |
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Telephone | 920-693-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 8882-031
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License Number State | WI
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