1265983076 NPI number — BELLEFAIRE JCB

Table of content: (NPI 1265983076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265983076 NPI number — BELLEFAIRE JCB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLEFAIRE JCB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265983076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22001 FAIRMOUNT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAKER HTS.
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44118-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-921-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22001 FAIRMOUNT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAKER HTS,.
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44118-8919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-921-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROSENBLATT
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
216-320-8206

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  RN289240 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)