Healthcare Provider Details

I. General information

NPI: 1356082325
Provider Name (Legal Business Name): GBEHZON COMMUNITY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 ANSEL RD
CLEVELAND OH
44103-2261
US

IV. Provider business mailing address

18009 LAKE SHORE BLVD APT 303
CLEVELAND OH
44119-1244
US

V. Phone/Fax

Practice location:
  • Phone: 951-413-4908
  • Fax:
Mailing address:
  • Phone: 951-413-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SIMMON O. B. LOGAN SR.
Title or Position: CEO/PRESIDENT
Credential:
Phone: 951-413-4908