1770706285 NPI number — SHARON CLEVELAND L.C.P.C.

Table of content: SHARON CLEVELAND L.C.P.C. (NPI 1770706285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770706285 NPI number — SHARON CLEVELAND L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEVELAND
Provider First Name:
SHARON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.P.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770706285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 SUNNYSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEROME
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83338-5972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-324-1120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
834 FALLS AVE STE 1280
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-3364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-736-9990
Provider Business Practice Location Address Fax Number:
208-736-9995
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0011848 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: X5663 . This is a "BLU CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 481086633 . This is a "TAX IDENTIFICATION NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805997100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010003974 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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