Provider Demographics
NPI:1760903918
Name:PROGRESSIVE LIFE CHANGERS
Entity Type:Organization
Organization Name:PROGRESSIVE LIFE CHANGERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:O'BRYAN
Authorized Official - Last Name:CURLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-726-2590
Mailing Address - Street 1:1101 BELLEVIEW ST STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1863
Mailing Address - Country:US
Mailing Address - Phone:704-726-2590
Mailing Address - Fax:980-422-0161
Practice Address - Street 1:1101 BELLEVIEW ST STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1863
Practice Address - Country:US
Practice Address - Phone:704-726-2590
Practice Address - Fax:980-422-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7961Medicaid
SCGP7961Medicaid