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General NPI Number Information
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NPI Number | 1063918472
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Entity Type | Organization
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Legal Business Name | CHANGE INCORPORATED
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Dates
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Enumeration Date | 04/04/2018
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Last Update Date | 04/04/2018
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Provider Practice Location Address
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Address Line | 29 BRUIN DR
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City | WELLSBURG
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State | WV
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Zip | 26070-3064
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Country | US
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Telephone | 47-977-7333
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Fax |
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Provider Business Mailing Address
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Address Line | 3158 WEST ST
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City | WEIRTON
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State | WV
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Zip | 26062-4637
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Country | US
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Telephone | 130-479-7773
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JUDY L RAVEAUX
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Credential |
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Telephone | 304-797-7733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number | 2271-6959
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License Number State | WV
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