Provider Demographics
NPI:1700697976
Name:LIFE CHANGE CORP
Entity type:Organization
Organization Name:LIFE CHANGE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TLAHJONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-799-2757
Mailing Address - Street 1:7141 W CARTER RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-7059
Mailing Address - Country:US
Mailing Address - Phone:602-799-2757
Mailing Address - Fax:
Practice Address - Street 1:2995 W FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4614
Practice Address - Country:US
Practice Address - Phone:602-799-2757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No385H00000XRespite Care FacilityRespite Care