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General NPI Number Information
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NPI Number | 1144642414
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Entity Type | Organization
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Legal Business Name | FOUNDATION OF CHANGE LLC
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Dates
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Enumeration Date | 01/06/2014
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Last Update Date | 01/07/2014
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Provider Practice Location Address
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Address Line | 912 E SAHARA AVE
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City | LAS VEGAS
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State | NV
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Zip | 89104-3004
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Country | US
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Telephone | 702-818-0847
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Fax |
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Provider Business Mailing Address
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Address Line | 10120 W FLAMINGO RD # 4-198
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City | LAS VEGAS
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State | NV
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Zip | 89147-8392
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Country | US
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Telephone | 702-818-0847
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | VITA JOHNSON
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Credential |
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Telephone | 702-818-0847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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