Provider Demographics
NPI:1467704437
Name:LIFE CHANGE OUTREACH ORGANIZATION
Entity Type:Organization
Organization Name:LIFE CHANGE OUTREACH ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NABUCHI
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-255-6458
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-0444
Mailing Address - Country:US
Mailing Address - Phone:352-255-6458
Mailing Address - Fax:
Practice Address - Street 1:1135 TENTH ST
Practice Address - Street 2:SUITE A
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-255-6458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004444700Medicaid