MEDICARE: THE CORNER CLUB FIGHT CAMP 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1568325561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CORNER CLUB FIGHT CAMP LLC

Provider Business Mailing Address
First Line	:	10229 BRIGGS RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3823
Country	:	US
Telephone Number	:	216-799-2446
Fax Number	:

Provider Business Practice Location Address
First Line	:	10229 BRIGGS RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3823
Country	:	US
Telephone Number	:	216-799-2446
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PRENICE LEE VON BREWER JR.
Credential	:
Telephone Number	:	216-799-2446

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	12/09/2025

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