Provider Demographics
NPI:1720390362
Name:CHANGE CENTER FOR VITALITY
Entity Type:Organization
Organization Name:CHANGE CENTER FOR VITALITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-324-8649
Mailing Address - Street 1:400 W CAPITOL AVE
Mailing Address - Street 2:STE 100D
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72201-3436
Mailing Address - Country:US
Mailing Address - Phone:501-324-2649
Mailing Address - Fax:
Practice Address - Street 1:400 W CAPITOL AVE
Practice Address - Street 2:STE 100D
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-3436
Practice Address - Country:US
Practice Address - Phone:501-324-2649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty