Provider Demographics
NPI:1144642414
Name:FOUNDATION OF CHANGE LLC
Entity type:Organization
Organization Name:FOUNDATION OF CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-818-0847
Mailing Address - Street 1:10120 W FLAMINGO RD # 4-198
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8392
Mailing Address - Country:US
Mailing Address - Phone:702-818-0847
Mailing Address - Fax:
Practice Address - Street 1:912 E SAHARA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3004
Practice Address - Country:US
Practice Address - Phone:702-818-0847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health