Provider Demographics
NPI:1902387400
Name:LIVING CHANGE CORPORATION
Entity Type:Organization
Organization Name:LIVING CHANGE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:COULTHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-570-0880
Mailing Address - Street 1:301 CASTEEL RD SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1611
Mailing Address - Country:US
Mailing Address - Phone:678-570-0880
Mailing Address - Fax:678-290-2850
Practice Address - Street 1:301 CASTEEL RD SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1611
Practice Address - Country:US
Practice Address - Phone:678-570-0880
Practice Address - Fax:678-290-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA005765251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA587942289AMedicaid