Basic Information
| Provider Information | |||||||||
| NPI: | 1316130784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHANGE ACADEMY AT LAKE OF THE OZARKS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MING AVE STE 265 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933094689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 CALO LANE | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF REVENUE CYCLE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6618294060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 105270 | MO | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 3404547 | 05 | NC | MEDICAID | 179084125 | 05 | AR | MEDICAID |