Healthcare Provider Details

I. General information

NPI: 1952716433
Provider Name (Legal Business Name): CHANGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LURAY DR
WINTERSVILLE OH
43953-3973
US

IV. Provider business mailing address

3136 WEST ST
WEIRTON WV
26062-4637
US

V. Phone/Fax

Practice location:
  • Phone: 740-314-8258
  • Fax: 304-723-2195
Mailing address:
  • Phone: 304-797-7733
  • Fax: 304-723-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JUDY RAVEAUX
Title or Position: CEO
Credential:
Phone: 304-797-7733