MEDICARE: CLEVELAND HEALTH VENTURES LLC

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
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225205800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND HEALTH VENTURES LLC

Provider Business Mailing Address
First Line	:	PO BOX 601544
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1544
Country	:	US
Telephone Number	:	803-222-0600
Fax Number	:	803-222-6119

Provider Business Practice Location Address
First Line	:	3420 FILBERT HWY
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-5602
Country	:	US
Telephone Number	:	803-222-0600
Fax Number	:	803-222-6119

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	MR. DANIEL L WIENS
Credential	:
Telephone Number	:	704-355-0648

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	10/23/2008

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Directions to “CLEVELAND HEALTH VENTURES LLC ” Practice Location

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