Provider Demographics
NPI:1629337704
Name:BELLEFAIRE JCB
Entity Type:Organization
Organization Name:BELLEFAIRE JCB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:C
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-320-8222
Mailing Address - Street 1:22001 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4819
Mailing Address - Country:US
Mailing Address - Phone:216-932-2800
Mailing Address - Fax:216-932-6704
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4819
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:216-932-6704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINGSPAN CARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-10
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02447261QR0405X, 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
OH10415Medicaid
OH02447Medicaid