Basic Information
| Provider Information | |||||||||
| NPI: | 1134427222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLEFAIRE JCB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1866 S COMPTON RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441182110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
| FaxNumber: | 2163208739 | ||||||||
| Practice Location | |||||||||
| Address1: | 1866 S COMPTON RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441182110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
| FaxNumber: | 2163208739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2011 | ||||||||
| LastUpdateDate: | 03/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | ALVA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2163208472 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | LSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | S002261 | OH | Y | Agencies | Foster Care Agency |
No ID Information.