Provider Demographics
NPI:1689829293
Name:LIFE CHANGEZ INC
Entity type:Organization
Organization Name:LIFE CHANGEZ INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RENE
Authorized Official - Middle Name:COFER
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-538-8920
Mailing Address - Street 1:1100 LOGGER CT
Mailing Address - Street 2:SUITE A102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-8525
Mailing Address - Country:US
Mailing Address - Phone:919-538-8920
Mailing Address - Fax:
Practice Address - Street 1:2856 CORNWALLIS RD
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-8140
Practice Address - Country:US
Practice Address - Phone:919-803-2799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 322D00000X
NCMHL-092-728320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604373Medicaid