Provider Demographics
NPI:1093111981
Name:BELLEFAIRE JCB
Entity type:Organization
Organization Name:BELLEFAIRE JCB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-320-8221
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:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12-2049251X00000X, 261QD1600X, 261QM0855X, 320800000X, 320900000X, 323P00000X, 385HR2055X, 385HR2065X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251X00000XAgenciesSupports Brokerage
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847183Medicaid
OH0525337Medicaid
OH2864226Medicaid
OH02447OtherUPIN
OH2419958OtherMRDD - ODJFS