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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1831412337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND HEALTH VENTURES LLC

Provider Business Mailing Address
First Line	:	PO BOX 601884
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1884
Country	:	US
Telephone Number	:	704-434-0990
Fax Number	:	704-434-4999

Provider Business Practice Location Address
First Line	:	335A W COLLEGE AVE
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28152-8111
Country	:	US
Telephone Number	:	704-434-0990
Fax Number	:	704-434-4999

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

Provider Enumeration Date	:	03/11/2010
Last Update Date	:	01/25/2013

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