Healthcare Provider Details

I. General information

NPI: 1558591685
Provider Name (Legal Business Name): LIFE CHANGING BEHAVIRAL HEALTH SER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
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: 910-628-9091
  • Fax: 910-628-9093
Mailing address:
  • Phone: 910-628-9091
  • Fax: 910-628-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LUIS JOEL ROMAN
Title or Position: COO
Credential:
Phone: 910-628-9091