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NPI Code Detail

MEDICARE: CLEVELAND VA CBOC

MEDICARE: CLEVELAND VA CBOC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1164W00000XLicensed Practical Nurse18107-031WI

General Provider Information

NPI Number : 1063439966
Entity Type Code : Organization
Provider Name (Legal Business Name) : CLEVELAND VA CBOC
Provider Business Mailing Address
First Line : 631 MARK AVE
Second Line :
City : SHEBOYGAN FALLS
State : WI
Zip : 53085-1721
Country : US
Telephone Number : 920-467-6079
Fax Number :
Provider Business Practice Location Address
First Line : 1205 NORTH AVE
Second Line :
City : CLEVELAND
State : WI
Zip : 53015-1413
Country : US
Telephone Number : 188-846-9661
Fax Number :
Authorized Official
Title or Position : LPN
Name : MRS. STACEY JEAN HIBBARD
Credential :
Telephone Number : 920-693-5600
Provider Enumeration Date : 07/16/2006
Last Update Date : 08/22/2020

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Directions to “CLEVELAND VA CBOC ” Practice Location

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