Provider Demographics
NPI:1720790447
Name:CHANGING LIVES NETWORKS INC
Entity Type:Organization
Organization Name:CHANGING LIVES NETWORKS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAQUAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-516-6187
Mailing Address - Street 1:823 DAY AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2505
Mailing Address - Country:US
Mailing Address - Phone:336-516-6187
Mailing Address - Fax:
Practice Address - Street 1:1020 BROOKSTOWN AVE STE 5&6
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2523
Practice Address - Country:US
Practice Address - Phone:336-293-6535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness