=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356082325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GBEHZON COMMUNITY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2022
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1031 ANSEL RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44103-2261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-413-4908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18009 LAKE SHORE BLVD APT 303
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44119-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-413-4908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | MR. SIMMON O. B. LOGAN SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-413-4908
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------