Healthcare Provider Details

I. General information

NPI: 1598442576
Provider Name (Legal Business Name): A BASE 4 CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N. ASHLEY DR. SUITE 600
TAMPA FL
33602
US

IV. Provider business mailing address

1633 NEW GARDEN RD # 1088
GREENSBORO NC
27410-2001
US

V. Phone/Fax

Practice location:
  • Phone: 919-799-3772
  • Fax:
Mailing address:
  • Phone: 919-799-3772
  • Fax:

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 Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VALLERY JOHNSON
Title or Position: CEO
Credential: BSN
Phone: 919-799-3772