Basic Information
| Provider Information | |||||||||
| NPI: | 1457747537 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLEFAIRE JCB | ||||||||
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| OtherOrganizationName: | MONARCH BOARDING ACADEMY - SOUTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 04/15/2015 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | BROWNE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2163208221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINGSPAN CARE GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251X00000X | 06-7516 | OH | N | Agencies | Supports Brokerage | 261QD1600X | 06-7516 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0855X | 06-7516 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 320800000X | 06-7516 | OH | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320900000X | 06-7516 | OH | N | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 323P00000X | 06-7516 | OH | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 385HR2055X | 06-7516 | OH | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 385HR2065X | 06-7516 | OH | N | Respite Care Facility | Respite Care | Respite Care, Physical Disabilities, Child | 320600000X | 06-7516 | OH | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 0525337 | 05 | OH | MEDICAID | 2419958 | 01 | OH | MRDD-ODJFS | OTHER | 02447 | 01 | OH | UPIN | OTHER | 2847183 | 05 | OH | MEDICAID | 2864226 | 05 | OH | MEDICAID |