MEDICARE: 21DAYS2CHANGE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1053541102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	21DAYS2CHANGE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 57366
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73157-7366
Country	:	US
Telephone Number	:	405-816-7735
Fax Number	:	405-286-1380

Provider Business Practice Location Address
First Line	:	12032 N PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7827
Country	:	US
Telephone Number	:	405-816-7735
Fax Number	:	405-286-1380

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. JAMES O HALE
Credential	:	LPC
Telephone Number	:	405-816-7735

Provider Enumeration Date	:	07/23/2009
Last Update Date	:	07/23/2009

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