Provider Demographics
NPI:1013500420
Name:CHANGING LIVES FAMILY CARE OF GEORGIA LLC
Entity type:Organization
Organization Name:CHANGING LIVES FAMILY CARE OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-739-1666
Mailing Address - Street 1:100 BULL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-3378
Mailing Address - Country:US
Mailing Address - Phone:757-739-1666
Mailing Address - Fax:804-884-3702
Practice Address - Street 1:100 BULL ST STE 200
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-3378
Practice Address - Country:US
Practice Address - Phone:757-739-1666
Practice Address - Fax:804-884-3702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA251E00000XMedicaid
GA3747P1801XMedicaid