Provider Demographics
NPI:1376802249
Name:BELLEFAIRE JCB
Entity Type:Organization
Organization Name:BELLEFAIRE JCB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-320-8221
Mailing Address - Street 1:347 MIDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-9006
Mailing Address - Country:US
Mailing Address - Phone:440-324-5701
Mailing Address - Fax:440-324-9978
Practice Address - Street 1:347 MIDWAY BLVD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-9006
Practice Address - Country:US
Practice Address - Phone:440-324-5701
Practice Address - Fax:440-324-9978
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINGSPAN CARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-11
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0009261QR0405X, 324500000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH02477Medicaid
OH10415Medicaid