Basic Information
| Provider Information | |||||||||
| NPI: | 1295239572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEFAIRE JEWISH CHILDREN'S BUREAU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163208222 | ||||||||
| FaxNumber: | 2133208733 | ||||||||
| Practice Location | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163208222 | ||||||||
| FaxNumber: | 2133208733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | LEIGH | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2163208222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 31712 | OH | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 3107739 | 05 | OH | MEDICAID |