=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730588955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CLEVELAND CLINIC FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 ASPIRA CT
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-4125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-756-2122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9500 EUCLID AVE JJ10
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44195-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ACCOUNTING OFFICER
-----------------------------------------------------
Name | TIM LONGVILLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-636-7416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 022412450
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------