=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417550567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 2D CHANGE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2020
-----------------------------------------------------
Last Update Date | 04/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2725 S. JONES BLVD. SUITE 101
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-829-6429
-----------------------------------------------------
Fax | 702-208-2090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9602
-----------------------------------------------------
City | NELLIS AFB
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-588-3425
-----------------------------------------------------
Fax | 702-208-2090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROOSEVELT DAYMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-588-3425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------