Provider Demographics
NPI:1992057723
Name:LIFE CHANGE OUTREACH ORGANIZATION
Entity type:Organization
Organization Name:LIFE CHANGE OUTREACH ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NABUCHI
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-255-6458
Mailing Address - Street 1:15508 WILLET CT
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9102
Mailing Address - Country:US
Mailing Address - Phone:352-255-6458
Mailing Address - Fax:
Practice Address - Street 1:15508 WILLET CT
Practice Address - Street 2:
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9102
Practice Address - Country:US
Practice Address - Phone:352-255-6458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty