Basic Information
Provider Information | |||||||||
NPI: | 1093111981 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BELLEFAIRE JCB | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONARCH BOARDING ACADEMY - EAST | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22001 FAIRMOUNT BLVD | ||||||||
Address2: |   | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441184819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2169322800 | ||||||||
FaxNumber: | 2169326704 | ||||||||
Practice Location | |||||||||
Address1: | 22001 FAIRMOUNT BLVD | ||||||||
Address2: |   | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441184819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2169322800 | ||||||||
FaxNumber: | 2169326704 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2014 | ||||||||
LastUpdateDate: | 11/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWNE | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2163208221 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WINGSPAN CARE GROUP | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251X00000X | 12-2049 | OH | N |   | Agencies | Supports Brokerage |   | 261QD1600X | 12-2049 | OH | N |   | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0855X | 12-2049 | OH | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 320800000X | 12-2049 | OH | N |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   | 320900000X | 12-2049 | OH | N |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   | 323P00000X | 12-2049 | OH | N |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   | 385HR2055X | 12-2049 | OH | N |   | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 385HR2065X | 12-2049 | OH | N |   | Respite Care Facility | Respite Care | Respite Care, Physical Disabilities, Child | 320600000X | 12-2049 | OH | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   |
ID Information
ID | Type | State | Issuer | Description | 2847183 | 05 | OH |   | MEDICAID | 0525337 | 05 | OH |   | MEDICAID | 2864226 | 05 | OH |   | MEDICAID | 02447 | 01 | OH | UPIN | OTHER | 2419958 | 01 | OH | MRDD - ODJFS | OTHER |