Provider Demographics
NPI:1720156011
Name:LIFE CENTER FOR CHANGE
Entity Type:Organization
Organization Name:LIFE CENTER FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-745-0467
Mailing Address - Street 1:240 S 5TH W STE D
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1476
Mailing Address - Country:US
Mailing Address - Phone:208-745-0467
Mailing Address - Fax:208-745-0409
Practice Address - Street 1:240 S 5TH W STE D
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1476
Practice Address - Country:US
Practice Address - Phone:208-745-0467
Practice Address - Fax:208-745-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID136534Medicare ID - Type Unspecified