MEDICARE: LIFE CHANGE OUTREACH ORGANIZATION, 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	251E00000X	Home Health Agency	232916	FL
2	253Z00000X	In Home Supportive Care Agency	232916	FL
3	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1982036133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGE OUTREACH ORGANIZATION, INC

Provider Business Mailing Address
First Line	:	55 BLUFF LAKE RD
Second Line	:	SUITE A
City	:	MASCOTTE
State	:	FL
Zip	:	34753-9501
Country	:	US
Telephone Number	:	352-255-6458
Fax Number	:	352-410-6118

Provider Business Practice Location Address
First Line	:	55 BLUFF LAKE RD
Second Line	:	SUITE A
City	:	MASCOTTE
State	:	FL
Zip	:	34753-9501
Country	:	US
Telephone Number	:	352-255-6458
Fax Number	:	352-410-6118

Authorized Official
Title or Position	:	PROGRAM MANAGER, OWNER
Name	:	MRS. NABUCHI G ANDERSON
Credential	:	REGISTERED MHC
Telephone Number	:	352-255-6458

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	07/30/2013

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