Provider Demographics
NPI:1952369514
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:JOHNSON
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:216-320-8222
Mailing Address - Fax:216-320-8733
Practice Address - Street 1:1865 N RIDGE RD E STE D-E
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3300
Practice Address - Country:US
Practice Address - Phone:440-324-5701
Practice Address - Fax:440-277-0459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINGSPAN CARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-03
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01-0009251S00000X
OH0009261QM0801X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH02447Medicaid
OH10415Medicaid
OH0525337OtherDEPT OF JOB & FAMILY SERVICES - MEDICAID ID
OH10415Medicaid
OH2419958OtherDEPT OF JOB & FAMILY SERVICES - MEDICAID PROVIDER NUMBER
OH1815525OtherDEPT OF DEVELOPMENTAL DISABILITIES - FACILITY NUMBER