Provider Demographics
NPI:1245244367
Name:CHANGE, INCORPORATED
Entity Type:Organization
Organization Name:CHANGE, INCORPORATED
Other - Org Name:FAMILY MEDICAL CARE COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RAVEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-797-7733
Mailing Address - Street 1:3136 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4635
Mailing Address - Country:US
Mailing Address - Phone:304-797-7733
Mailing Address - Fax:
Practice Address - Street 1:3136 WEST ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4635
Practice Address - Country:US
Practice Address - Phone:304-797-7733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2161000OtherCHANGE DBA FAMILY MEDICAL CARE CHC
OH2733993Medicaid
WV3810007536Medicaid
OH361015Other200 LURAY DRIVE WINTERSVILLE OH MEDICARE SITE #
OH2160961OtherCHANGE OH LICENSE
OH2161000OtherCHANGE DBA FAMILY MEDICAL CARE CHC
OH361015Other200 LURAY DRIVE WINTERSVILLE OH MEDICARE SITE #
WV3810007536Medicaid
WV511950Medicare UPIN