Organization
CHANGING LIVES GROUP HOME IV , LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAQUAY WADE (DIRECTOR)
(336) 516-6187
Entity
Organization
Contact information
Practice address
1404 CUSHING ST, GREENSBORO, NC 27405-3300
(336) 516-6187
Mailing address
823 DAY AVE, BURLINGTON, NC 27217-2505
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
311ZA0620X
Adult Care Home Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1760905178
—
NC
Enumeration date
07/18/2017
Last updated
09/30/2020
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