=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518417583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CHANGE FAMILY SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 10/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20018 N TOLEDO AVE
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-374-0072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20018 N TOLEDO AVE
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-374-0072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. CLAUDETTE WALKER
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 520-374-0072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | BH 5008
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------