Provider Demographics
NPI:1194095893
Name:CLEVELAND JUVENILE JUSTICE AND DELINQUENCY PREVENTIN CENTER
Entity type:Organization
Organization Name:CLEVELAND JUVENILE JUSTICE AND DELINQUENCY PREVENTIN CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER,
Authorized Official - Phone:216-754-0615
Mailing Address - Street 1:3385 E 147TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-4133
Mailing Address - Country:US
Mailing Address - Phone:216-754-0615
Mailing Address - Fax:
Practice Address - Street 1:3385 EAST 147TH STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120
Practice Address - Country:US
Practice Address - Phone:216-754-0615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAY INTERNATIONAL OF CLEVELAND CHURCH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-11
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHEXEMPTION/ CLERGY251V00000X
OHEXEMPTION251V00000X, 252Y00000X
324500000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No252Y00000XAgenciesEarly Intervention Provider Agency
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHEXEMPTION/ CLERGYMedicaid