Healthcare Provider Details

I. General information

NPI: 1093111981
Provider Name (Legal Business Name): BELLEFAIRE JCB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

IV. Provider business mailing address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

V. Phone/Fax

Practice location:
  • Phone: 216-932-2800
  • Fax: 216-932-6704
Mailing address:
  • Phone: 216-932-2800
  • Fax: 216-932-6704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number12-2049
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number12-2049
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number12-2049
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number12-2049
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number12-2049
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number12-2049
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number12-2049
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number12-2049
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number12-2049
License Number StateOH

VIII. Authorized Official

Name: MR. THOMAS J BROWNE
Title or Position: CFO
Credential:
Phone: 216-320-8221