Provider Demographics
NPI:1942618228
Name:CHANGES
Entity Type:Organization
Organization Name:CHANGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LOLITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-368-0005
Mailing Address - Street 1:19940 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1494
Mailing Address - Country:US
Mailing Address - Phone:313-368-0005
Mailing Address - Fax:313-368-0771
Practice Address - Street 1:19940 CONANT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1494
Practice Address - Country:US
Practice Address - Phone:313-368-0005
Practice Address - Fax:313-368-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0823210207RA0401X, 261QM2800X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No251B00000XAgenciesCase Management