=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952369514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLEFAIRE JCB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 02/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1865 N RIDGE RD E STE D-E
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44055-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-324-5701
-----------------------------------------------------
Fax | 440-277-0459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22001 FAIRMOUNT BLVD
-----------------------------------------------------
City | SHAKER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44118-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-320-8222
-----------------------------------------------------
Fax | 216-320-8733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL COUNSEL
-----------------------------------------------------
Name | LEIGH JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-320-8222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 01-0009
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------