Basic Information
| Provider Information | |||||||||
| NPI: | 1871950709 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONARCH LIFEWORKS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MONARCH LIFEWORKS - XANTHOS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21450 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163715051 | ||||||||
| FaxNumber: | 2169326704 | ||||||||
| Practice Location | |||||||||
| Address1: | 21450 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163715051 | ||||||||
| FaxNumber: | 2169326704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2016 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2169322800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BELLEFAIRE JCB | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 31712 | OH | N | Agencies | Community/Behavioral Health | 320600000X | 31712 | OH | N | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 31712 | 01 | OH | OHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES CERTIFICATE NUMBER | OTHER | 0078929 | 05 | OH | MEDICAID | 1815525 | 01 | OH | OHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES FACILITY NUMBER | OTHER |