1568188340 NPI number — CHANGE ACADEMY AT LAKE OF THE OZARKS

Table of content: DR. GREGORY KEITH MOORE MD (NPI 1417958760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568188340 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:
1568188340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2025
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:
20116 ASHBROOK PL STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHBURN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20147-5086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-550-9281
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SPENCER
Authorized Official First Name:
SHARNELL
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
661-239-6923

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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