Provider Demographics
NPI:1558096701
Name:LIFES CHANGES CENTER FOR WELLNESS
Entity Type:Organization
Organization Name:LIFES CHANGES CENTER FOR WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:810-252-7994
Mailing Address - Street 1:G3100 MILLER RD APT 19C
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1323
Mailing Address - Country:US
Mailing Address - Phone:810-252-7994
Mailing Address - Fax:
Practice Address - Street 1:2425 S LINDEN RD STE D138
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5482
Practice Address - Country:US
Practice Address - Phone:810-252-7994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center