Provider Demographics
NPI:1235470378
Name:LIFE CHANGE
Entity Type:Organization
Organization Name:LIFE CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-614-6336
Mailing Address - Street 1:9 GRANT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PITTSVIEW
Mailing Address - State:AL
Mailing Address - Zip Code:36871-2521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 GRANT CIR
Practice Address - Street 2:
Practice Address - City:PITTSVIEW
Practice Address - State:AL
Practice Address - Zip Code:36871-2516
Practice Address - Country:US
Practice Address - Phone:334-614-6336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1566261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care