Provider Demographics
NPI:1912020637
Name:LIFE CHANGEZ, INC
Entity Type:Organization
Organization Name:LIFE CHANGEZ, INC
Other - Org Name:LIFE SKILLS INDEPENDENT CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DIRECTO
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-803-2799
Mailing Address - Street 1:1100 LOGGER CT
Mailing Address - Street 2:SUITE A102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-8525
Mailing Address - Country:US
Mailing Address - Phone:919-803-2799
Mailing Address - Fax:919-803-2808
Practice Address - Street 1:800 PERRY HOWARD RD
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1779
Practice Address - Country:US
Practice Address - Phone:919-577-0021
Practice Address - Fax:919-803-2808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 322D00000X
NCMHL-092-795320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604442Medicaid