Provider Demographics
NPI:1659737286
Name:LIFE CHANGING ADULT DAYCARE
Entity Type:Organization
Organization Name:LIFE CHANGING ADULT DAYCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-207-3645
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:2110 KINLOCK ROAD
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-0053
Mailing Address - Country:US
Mailing Address - Phone:662-207-3645
Mailing Address - Fax:
Practice Address - Street 1:305 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2107
Practice Address - Country:US
Practice Address - Phone:662-207-3645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty