MEDICARE: TOTAL LIFE CHANGE 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1659973055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL LIFE CHANGE INC

Provider Business Mailing Address
First Line	:	1300 E SHAW AVE STE 121
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-7903
Country	:	US
Telephone Number	:	559-479-9779
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 E SHAW AVE STE 121
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-7903
Country	:	US
Telephone Number	:	559-479-9779
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	TOD HARRIS
Credential	:
Telephone Number	:	559-479-9779

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	11/10/2020

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