Healthcare Provider Details

I. General information

NPI: 1215524756
Provider Name (Legal Business Name): INNERCHANGE LAKE HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 LILY PAD LN
FLAT ROCK NC
28731-9503
US

IV. Provider business mailing address

5500 MING AVE STE 410
BAKERSFIELD CA
93309-4631
US

V. Phone/Fax

Practice location:
  • Phone: 435-229-5498
  • Fax:
Mailing address:
  • Phone: 661-622-4132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA J BROWN
Title or Position: VP OF REVENUE CYCLE MANAGEMENT
Credential:
Phone: 661-829-4060