Healthcare Provider Details

I. General information

NPI: 1457282980
Provider Name (Legal Business Name): CHANGING LIVES AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5284 FLOYD RD SW UNIT 2079
MABLETON GA
30126-6120
US

IV. Provider business mailing address

5284 FLOYD RD SW UNIT 2079
MABLETON GA
30126-6120
US

V. Phone/Fax

Practice location:
  • Phone: 678-396-1803
  • Fax:
Mailing address:
  • Phone: 678-396-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: BONIAT JEMISON
Title or Position: OWNER
Credential:
Phone: 678-396-1803