Provider Demographics
NPI:1174074686
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:
Authorized Official - Last Name:RAVEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-797-7733
Mailing Address - Street 1:3158 WEST STREET
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062
Mailing Address - Country:US
Mailing Address - Phone:304-459-4010
Mailing Address - Fax:304-723-2195
Practice Address - Street 1:1151 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWELL
Practice Address - State:WV
Practice Address - Zip Code:26050
Practice Address - Country:US
Practice Address - Phone:304-459-4010
Practice Address - Fax:304-797-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV511097Medicare Oscar/Certification