Healthcare Provider Details

I. General information

NPI: 1184226409
Provider Name (Legal Business Name): LIFE CHANGEZ, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 MAYWOOD ST
GREENSBORO NC
27403-3107
US

IV. Provider business mailing address

1100 LOGGER CT STE A102
RALEIGH NC
27609-8506
US

V. Phone/Fax

Practice location:
  • Phone: 919-803-2799
  • Fax: 919-802-2808
Mailing address:
  • Phone: 919-538-8920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: RENE WHITEHEAD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-538-8920