Provider Demographics
NPI:1619503422
Name:CHANGE INC
Entity Type:Organization
Organization Name:CHANGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAVEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-797-7733
Mailing Address - Street 1:3158 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4637
Mailing Address - Country:US
Mailing Address - Phone:304-797-1210
Mailing Address - Fax:
Practice Address - Street 1:114 TAYLOR AVE
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:304-748-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)