Provider Demographics
NPI:1992846869
Name:THE CENTER OF CHANGE
Entity Type:Organization
Organization Name:THE CENTER OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEBURN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-755-7787
Mailing Address - Street 1:PO BOX 12043
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29211-2043
Mailing Address - Country:US
Mailing Address - Phone:803-755-7787
Mailing Address - Fax:803-755-2666
Practice Address - Street 1:1228 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-4026
Practice Address - Country:US
Practice Address - Phone:803-755-7787
Practice Address - Fax:803-755-2666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC930MXHMedicaid