Provider Demographics
NPI:1033348693
Name:CENTER FOR CHANGE
Entity Type:Organization
Organization Name:CENTER FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:316-201-1234
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-0250
Mailing Address - Country:US
Mailing Address - Phone:316-722-2448
Mailing Address - Fax:866-316-4467
Practice Address - Street 1:1333 N BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2894
Practice Address - Country:US
Practice Address - Phone:316-201-1234
Practice Address - Fax:866-316-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-03
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone