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General NPI Number Information
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NPI Number | 1669428959
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Entity Type | Organization
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Legal Business Name | CLEVELAND NEUROLOGIC CLINIC, PA
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Dates
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Enumeration Date | 05/26/2006
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Last Update Date | 11/06/2008
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Provider Practice Location Address
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Address Line | 1180 WYKE RD SUITE B
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City | SHELBY
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State | NC
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Zip | 28150-4259
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Country | US
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Telephone | 704-471-9895
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Fax | 704-471-9200
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Provider Business Mailing Address
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Address Line | 1180 WYKE RD SUITE B
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City | SHELBY
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State | NC
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Zip | 28150-4259
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Country | US
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Telephone | 704-471-9895
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Fax | 704-471-9200
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. JERRY MARTIN
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Credential |
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Telephone | 704-471-9895
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 729676
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License Number State | NC
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