MEDICARE: CLEVELAND JUVENILE JUSTICE AND DELINQUENCY PREVENTIN CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251V00000X	Voluntary or Charitable Agency	EXEMPTION	OH
2	3245S0500X	Children's Substance Abuse Rehabilitation Facility
3	324500000X	Substance Abuse Rehabilitation Facility
4	252Y00000X	Early Intervention Provider Agency	EXEMPTION	OH
5	251V00000X	Voluntary or Charitable Agency	EXEMPTION/ CLERGY	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194095893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND JUVENILE JUSTICE AND DELINQUENCY PREVENTIN CENTER

Provider Business Mailing Address
First Line	:	3385 E 147TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-4133
Country	:	US
Telephone Number	:	216-754-0615
Fax Number	:

Provider Business Practice Location Address
First Line	:	3385 EAST 147TH STREET
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120
Country	:	US
Telephone Number	:	216-754-0615
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CALVIN DRAKE
Credential	:	OWNER,
Telephone Number	:	216-754-0615

Provider Enumeration Date	:	01/11/2012
Last Update Date	:	03/14/2012

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