Provider Demographics
NPI:1063918472
Name:CHANGE INCORPORATED
Entity type:Organization
Organization Name:CHANGE INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAVEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-797-7733
Mailing Address - Street 1:3158 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4637
Mailing Address - Country:US
Mailing Address - Phone:130-479-7773
Mailing Address - Fax:
Practice Address - Street 1:29 BRUIN DR
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-3064
Practice Address - Country:US
Practice Address - Phone:047-977-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANGE INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2271-6959261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)