Healthcare Provider Details

I. General information

NPI: 1619100047
Provider Name (Legal Business Name): LIFE CHANGE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E 221ST ST
EUCLID OH
44117-1509
US

IV. Provider business mailing address

PO BOX 604002
CLEVELAND OH
44104-0002
US

V. Phone/Fax

Practice location:
  • Phone: 216-376-2886
  • Fax:
Mailing address:
  • Phone: 216-376-2886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BYRON R SWIFT
Title or Position: EXECUTIVE DIRECTR
Credential: LSW MSSA
Phone: 216-376-2886