Provider Demographics
NPI:1982036133
Name:LIFE CHANGE OUTREACH ORGANIZATION, INC
Entity Type:Organization
Organization Name:LIFE CHANGE OUTREACH ORGANIZATION, INC
Other - Org Name:LCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NABUCHI
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED MHC
Authorized Official - Phone:352-255-6458
Mailing Address - Street 1:55 BLUFF LAKE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9501
Mailing Address - Country:US
Mailing Address - Phone:352-255-6458
Mailing Address - Fax:352-410-6118
Practice Address - Street 1:55 BLUFF LAKE RD
Practice Address - Street 2:SUITE A
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9501
Practice Address - Country:US
Practice Address - Phone:352-255-6458
Practice Address - Fax:352-410-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FL232916251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care