Organization
LIFE CHANGE OUTREACH ORGANIZATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. NABUCHI GRACE ANDERSON (OWNER)
(352) 255-6458
Entity
Organization
Contact information
Practice address
1135 TENTH ST, SUITE A, CLERMONT, FL 34711
(352) 255-6458
Mailing address
PO BOX 444, MASCOTTE, FL 34753-0444
(352) 255-6458
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
—
—
171M00000X
Case Manager/Care Coordinator
Primary
—
—
305S00000X
Point of Service
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004444700
—
FL
Enumeration date
10/15/2012
Last updated
10/15/2012
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