Provider Demographics
NPI:1497151104
Name:BELLEFAIRE JCB
Entity type:Organization
Organization Name:BELLEFAIRE JCB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-320-8222
Mailing Address - Street 1:22001 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4819
Mailing Address - Country:US
Mailing Address - Phone:216-932-2800
Mailing Address - Fax:216-932-6704
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4819
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:216-932-6704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINGSPAN CARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-06
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12-1949323P00000X, 261QD1600X, 261QM0855X, 320600000X, 320800000X, 320900000X, 323P00000X, 385HR2055X, 385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTBDMedicaid
OH06-8251OtherODMHAS LICENSE
OH0525337Medicaid
OH2847183Medicaid
OH2419958OtherMRDD - ODJFS