=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508683970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DON'T BE AFRAID TO CHANGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2024
-----------------------------------------------------
Last Update Date | 09/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 8TH AVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95820-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-956-9759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 836 57TH ST STE 476
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-713-3049
-----------------------------------------------------
Fax | 916-713-3051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR/CEO
-----------------------------------------------------
Name | VANCE GUY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-713-3049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------