Healthcare Provider Details

I. General information

NPI: 1912368176
Provider Name (Legal Business Name): COURAGE TO CHANGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N ANDERSON RD
EXETER CA
93221-9674
US

IV. Provider business mailing address

252 HIGH SIERRA DR
EXETER CA
93221-9502
US

V. Phone/Fax

Practice location:
  • Phone: 559-594-4855
  • Fax: 559-594-0086
Mailing address:
  • Phone: 559-594-4855
  • Fax: 559-594-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number247200700
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number540014BN
License Number StateCA

VIII. Authorized Official

Name: MRS. SUSAN GAMBINI
Title or Position: ADMINISTRATOR
Credential:
Phone: 559-594-4855