Healthcare Provider Details

I. General information

NPI: 1144891599
Provider Name (Legal Business Name): CHANGE THE INFLUENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16801 VAN BUREN BLVD
RIVERSIDE CA
92504-5896
US

IV. Provider business mailing address

16801 VAN BUREN BLVD
RIVERSIDE CA
92504-5896
US

V. Phone/Fax

Practice location:
  • Phone: 760-636-9226
  • Fax:
Mailing address:
  • Phone: 760-636-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MERCEDES MONTANA
Title or Position: CEO
Credential:
Phone: 760-636-9226