Provider Demographics
NPI:1659973055
Name:TOTAL LIFE CHANGE INC
Entity Type:Organization
Organization Name:TOTAL LIFE CHANGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOD
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-479-9779
Mailing Address - Street 1:1300 E SHAW AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7903
Mailing Address - Country:US
Mailing Address - Phone:559-479-9779
Mailing Address - Fax:
Practice Address - Street 1:1300 E SHAW AVE STE 121
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7903
Practice Address - Country:US
Practice Address - Phone:559-479-9779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health