Provider Demographics
NPI:1225401912
Name:LIFE CHANGE OUTREACH ORGANIZATION, INC
Entity Type:Organization
Organization Name:LIFE CHANGE OUTREACH ORGANIZATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-272-2799
Mailing Address - Street 1:15508 WILLET CT
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9102
Mailing Address - Country:US
Mailing Address - Phone:352-272-2799
Mailing Address - Fax:352-410-6111
Practice Address - Street 1:15508 WILLET CT
Practice Address - Street 2:
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9102
Practice Address - Country:US
Practice Address - Phone:352-272-2799
Practice Address - Fax:352-410-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health