Basic Information
Provider Information | |||||||||
NPI: | 1205893070 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BELLEFAIRE JCB | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
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: | 04/27/2006 | ||||||||
LastUpdateDate: | 02/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | LEIGH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 2163208222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WINGSPAN CARE GROUP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | 71376 | OH | N |   | Agencies | Foster Care Agency |   | 320800000X | 0009 | OH | N |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   | 322D00000X | 0009 | OH | N |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   | 251B00000X | 71376 | OH | N |   | Agencies | Case Management |   | 251S00000X | 01-0009 | OH | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 01-0009 | 05 | OH |   | MEDICAID | 02447 | 05 | OH |   | MEDICAID |