MEDICARE: LIFE CHANGE OUTREACH ORGANIZATION, INC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1225401912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGE OUTREACH ORGANIZATION, INC

Provider Business Mailing Address
First Line	:	15508 WILLET CT
Second Line	:
City	:	MASCOTTE
State	:	FL
Zip	:	34753-9102
Country	:	US
Telephone Number	:	352-272-2799
Fax Number	:	352-410-6111

Provider Business Practice Location Address
First Line	:	15508 WILLET CT
Second Line	:
City	:	MASCOTTE
State	:	FL
Zip	:	34753-9102
Country	:	US
Telephone Number	:	352-272-2799
Fax Number	:	352-410-6111

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ANTHONY A ANDERSON
Credential	:
Telephone Number	:	352-272-2799

Provider Enumeration Date	:	11/04/2015
Last Update Date	:	11/04/2015

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