MEDICARE: LIFE CHANGE INSTITUTE, 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	251S00000X	Community/Behavioral Health Agency	I-06858	NM

General Provider Information

NPI Number	:	1962731174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGE INSTITUTE, LLC.

Provider Business Mailing Address
First Line	:	9301 INDIAN SCHOOL RD NE STE 103
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-2861
Country	:	US
Telephone Number	:	505-280-5860
Fax Number	:	505-294-3904

Provider Business Practice Location Address
First Line	:	9301 INDIAN SCHOOL RD NE STE 103
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-2861
Country	:	US
Telephone Number	:	505-280-5860
Fax Number	:	505-294-3904

Authorized Official
Title or Position	:	FOUNDER/OWNER
Name	:	MRS. SHANNON ENRIGHT-SMITH
Credential	:	LISW
Telephone Number	:	505-280-5860

Provider Enumeration Date	:	12/17/2009
Last Update Date	:	12/17/2009

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Directions to “LIFE CHANGE INSTITUTE, LLC. ” Practice Location

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