Healthcare Provider Details

I. General information

NPI: 1811208747
Provider Name (Legal Business Name): LIFE CHANGING BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S MAIN ST
FAIRMONT NC
28340-1906
US

IV. Provider business mailing address

314 S MAIN ST
FAIRMONT NC
28340-1906
US

V. Phone/Fax

Practice location:
  • Phone: 910-628-6476
  • Fax: 910-628-6531
Mailing address:
  • Phone: 910-628-6476
  • Fax: 910-628-6531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LUIS ROMAN
Title or Position: COO
Credential:
Phone: 910-770-2682