MEDICARE: CHANGING LIVES HEALTH CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1790253029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING LIVES HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	4911 W GOOD HOPE RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-4840
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4911 W GOOD HOPE RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-4840
Country	:	US
Telephone Number	:	414-477-9644
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	JORDON JACKSON
Credential	:
Telephone Number	:	414-477-9466

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	11/05/2018

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