Provider Demographics
NPI:1780123331
Name:LYFE CHANGES LLC
Entity type:Organization
Organization Name:LYFE CHANGES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-314-0383
Mailing Address - Street 1:7415 GATEHOUSE CIR
Mailing Address - Street 2:APT 180
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-6011
Mailing Address - Country:US
Mailing Address - Phone:407-314-0383
Mailing Address - Fax:407-964-3238
Practice Address - Street 1:7415 GATEHOUSE CIR
Practice Address - Street 2:APT 180
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-6011
Practice Address - Country:US
Practice Address - Phone:407-314-0383
Practice Address - Fax:407-964-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014194400Medicaid