1225645674 NPI number — CHANGE ACADEMY AT LAKE OF THE OZARKS

Table of content: (NPI 1225645674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225645674 NPI number — CHANGE ACADEMY AT LAKE OF THE OZARKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANGE ACADEMY AT LAKE OF THE OZARKS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225645674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5500 MING AVE STE 410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93309-4631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-622-4132
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5842 HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37307-4734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-205-5819
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT OF RCM
Authorized Official Telephone Number:
661-829-4060

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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