Healthcare Provider Details

I. General information

NPI: 1922056415
Provider Name (Legal Business Name): THE LIFE CHANGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 VINE ST
RENO NV
89503-5546
US

IV. Provider business mailing address

1755 SULLIVAN LN
SPARKS NV
89431-2815
US

V. Phone/Fax

Practice location:
  • Phone: 775-499-5534
  • Fax: 775-355-7759
Mailing address:
  • Phone: 775-355-7734
  • Fax: 775-355-7759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number138101
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN ZELLER
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 775-355-7734