Provider Demographics
NPI:1245498799
Name:CHANGEFORBETTERLIFE
Entity type:Organization
Organization Name:CHANGEFORBETTERLIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-966-6680
Mailing Address - Street 1:7511 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7001
Mailing Address - Country:US
Mailing Address - Phone:954-966-6680
Mailing Address - Fax:954-966-6680
Practice Address - Street 1:7511 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-7001
Practice Address - Country:US
Practice Address - Phone:954-966-6680
Practice Address - Fax:954-966-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101543FH251S00000X
FL261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675005296Medicaid