Provider Demographics
NPI:1205893070
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:
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:2006-04-27
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH71376251B00000X, 253J00000X
OH0009320800000X, 322D00000X, 323P00000X, 385HR2055X, 322D00000X
385H00000X
OH01-0009251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251B00000XAgenciesCase Management
No253J00000XAgenciesFoster Care Agency
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care
Yes251S00000XAgenciesCommunity/Behavioral Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01-0009Medicaid
OH02447Medicaid
OH2419958OtherDEPT OF JOB & FAMILY SERVICES - MEDICAID PROVIDER NUMBER
OH0525337OtherDEPT OF JOB & FAMILY SERVICES - MEDICAID ID
OH1815525OtherDEPT OF DEVELOPMENTAL DISABILITIES - FACILITY NUMBER