Healthcare Provider Details

I. General information

NPI: 1396515623
Provider Name (Legal Business Name): GENERATION CHANGERS LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 LIPSCOMB ST NE STE 6G
PALM BAY FL
32905-2929
US

IV. Provider business mailing address

4690 LIPSCOMB ST NE STE 6G
PALM BAY FL
32905-2929
US

V. Phone/Fax

Practice location:
  • Phone: 321-795-7094
  • Fax:
Mailing address:
  • Phone: 321-795-7094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: RACHAEL BROWN
Title or Position: OWNER
Credential:
Phone: 321-795-7094