Basic Information
| Provider Information | |||||||||
| NPI: | 1952369514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLEFAIRE JCB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163208222 | ||||||||
| FaxNumber: | 2163208733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1865 N RIDGE RD E STE D-E | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403245701 | ||||||||
| FaxNumber: | 4402770459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | LEIGH | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2163208222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINGSPAN CARE GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 01-0009 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 02447 | 05 | OH | MEDICAID | 10415 | 05 | OH | MEDICAID |