MEDICARE: CHANGE AGENTS OF SOCIAL SERVICES LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363LC1500X	Community Health Nurse Practitioner
2	171M00000X	Case Manager/Care Coordinator
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1780363044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGE AGENTS OF SOCIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	2709 POSITIVE CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0947
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2709 POSITIVE CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0947
Country	:	US
Telephone Number	:	702-305-0652
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	CHRISTOPHER HANNIBLE
Credential	:
Telephone Number	:	702-305-0652

Provider Enumeration Date	:	07/13/2023
Last Update Date	:	07/13/2023

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