MEDICARE: CHANGING LIVES 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1245954403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING LIVES LLC

Provider Business Mailing Address
First Line	:	8250 N GRAND CANYON DR UNIT 1147
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-3738
Country	:	US
Telephone Number	:	702-406-7870
Fax Number	:

Provider Business Practice Location Address
First Line	:	8250 N GRAND CANYON DR UNIT 1147
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-3738
Country	:	US
Telephone Number	:	702-406-7870
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESHA MURRY
Credential	:
Telephone Number	:	702-628-2887

Provider Enumeration Date	:	09/30/2022
Last Update Date	:	09/30/2022

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Directions to “CHANGING LIVES LLC ” Practice Location

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