Healthcare Provider Details

I. General information

NPI: 1750603288
Provider Name (Legal Business Name): POSITIVE LIFE CHANGES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MAIN ST
HOOKERTON NC
28538-0000
US

IV. Provider business mailing address

210 E MAIN ST
HOOKERTON NC
28538-0000
US

V. Phone/Fax

Practice location:
  • Phone: 252-557-0444
  • Fax: 252-557-0445
Mailing address:
  • Phone: 252-557-0444
  • Fax: 252-557-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: SHANA MIDGETTE
Title or Position: PRESIDENT/PROGRAM SUPERVISOR
Credential:
Phone: 252-557-0444