Provider Demographics
NPI:1750603288
Name:POSITIVE LIFE CHANGES
Entity type:Organization
Organization Name:POSITIVE LIFE CHANGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROGRAM SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDGETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-557-0444
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOOKERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28538-0000
Mailing Address - Country:US
Mailing Address - Phone:252-557-0444
Mailing Address - Fax:252-557-0445
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HOOKERTON
Practice Address - State:NC
Practice Address - Zip Code:28538-0000
Practice Address - Country:US
Practice Address - Phone:252-557-0444
Practice Address - Fax:252-557-0445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112264Medicaid