Provider Demographics
NPI:1003193889
Name:LIFE CHANGES - CAP SERVICES
Entity Type:Organization
Organization Name:LIFE CHANGES - CAP SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-537-0096
Mailing Address - Street 1:1001 E WT HARRIS BLVD
Mailing Address - Street 2:SUITE P-192
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4104
Mailing Address - Country:US
Mailing Address - Phone:704-537-0096
Mailing Address - Fax:704-537-6080
Practice Address - Street 1:1001 S MARSHALL ST
Practice Address - Street 2:SUITE 1-75
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5852
Practice Address - Country:US
Practice Address - Phone:704-537-0096
Practice Address - Fax:704-537-6080
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE CHANGES HOME CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC4410251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418536Medicaid