MEDICARE: A CHANGE COUNSELING CENTER

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	27125700	WA

General Provider Information

NPI Number	:	1881084473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A CHANGE COUNSELING CENTER

Provider Business Mailing Address
First Line	:	4002 S M ST
Second Line	:	SUITE C
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-473-1844
Fax Number	:	928-708-9620

Provider Business Practice Location Address
First Line	:	4002 S M ST
Second Line	:	SUITE C
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-473-1844
Fax Number	:	928-708-9620

Authorized Official
Title or Position	:	FACILITY COORDINATOR
Name	:	JOHN LEDOUX
Credential	:
Telephone Number	:	982-708-9615

Provider Enumeration Date	:	02/03/2015
Last Update Date	:	02/03/2015

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