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General NPI Number Information
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NPI Number | 1760905178
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Entity Type | Organization
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Legal Business Name | CHANGING LIVES GROUP HOME IV , LLC
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Dates
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Enumeration Date | 07/18/2017
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 1404 CUSHING ST
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City | GREENSBORO
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State | NC
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Zip | 27405-3300
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Country | US
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Telephone | 336-516-6187
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Fax |
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Provider Business Mailing Address
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Address Line | 823 DAY AVE
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City | BURLINGTON
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State | NC
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Zip | 27217-2505
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | JAQUAY WADE
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Credential |
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Telephone | 336-516-6187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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Taxonomy #2
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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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