Provider Demographics
NPI:1164756623
Name:LIFECHANGINGBEHAVIORALHEALTHSERVICES
Entity Type:Organization
Organization Name:LIFECHANGINGBEHAVIORALHEALTHSERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-770-2682
Mailing Address - Street 1:314 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-1906
Mailing Address - Country:US
Mailing Address - Phone:910-628-9091
Mailing Address - Fax:910-628-9093
Practice Address - Street 1:18 WHITEVILLE MINI MALL
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2105
Practice Address - Country:US
Practice Address - Phone:910-914-0006
Practice Address - Fax:910-914-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health