MEDICARE: CHANGE CENTER FOR VITALITY

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1720390362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGE CENTER FOR VITALITY

Provider Business Mailing Address
First Line	:	400 W CAPITOL AVE
Second Line	:	STE 100D
City	:	LITTLE ROCK
State	:	AR
Zip	:	72201-3436
Country	:	US
Telephone Number	:	501-324-2649
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 W CAPITOL AVE
Second Line	:	STE 100D
City	:	LITTLE ROCK
State	:	AR
Zip	:	72201-3436
Country	:	US
Telephone Number	:	501-324-2649
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEBRA VELEZ
Credential	:
Telephone Number	:	501-324-8649

Provider Enumeration Date	:	07/12/2010
Last Update Date	:	07/12/2010

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Directions to “CHANGE CENTER FOR VITALITY ” Practice Location

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