Provider Demographics
NPI:1831315449
Name:CHANGINGYOURLIFEADULT&YOUTHSERVICESLLC.
Entity Type:Organization
Organization Name:CHANGINGYOURLIFEADULT&YOUTHSERVICESLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:SHEDWICK
Authorized Official - Last Name:CAPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-994-3606
Mailing Address - Street 1:2498 US HIGHWAY 74 EAST
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170
Mailing Address - Country:US
Mailing Address - Phone:704-994-3606
Mailing Address - Fax:866-681-5406
Practice Address - Street 1:2498 US HIGHWAY 74 E
Practice Address - Street 2:2498 US HIGHWAY 74 EAST
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-6479
Practice Address - Country:US
Practice Address - Phone:704-994-3606
Practice Address - Fax:866-861-5406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities