Healthcare Provider Details

I. General information

NPI: 1982036133
Provider Name (Legal Business Name): LIFE CHANGE OUTREACH ORGANIZATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BLUFF LAKE RD SUITE A
MASCOTTE FL
34753-9501
US

IV. Provider business mailing address

55 BLUFF LAKE RD SUITE A
MASCOTTE FL
34753-9501
US

V. Phone/Fax

Practice location:
  • Phone: 352-255-6458
  • Fax: 352-410-6118
Mailing address:
  • Phone: 352-255-6458
  • Fax: 352-410-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number232916
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number232916
License Number StateFL

VIII. Authorized Official

Name: MRS. NABUCHI G ANDERSON
Title or Position: PROGRAM MANAGER, OWNER
Credential: REGISTERED MHC
Phone: 352-255-6458