Basic Information
| Provider Information | |||||||||
| NPI: | 1528469772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHANGE ACADEMY LAKE OZARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 CALO LN | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650499208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 CALO LN | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650499208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2014 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAGEMANN | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OTR/L | ||||||||
| AuthorizedOfficialTelephone: | 5735528007 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 016604 | MO | N | Agencies | Home Health | 252Y00000X | 016604 | MO | N | Agencies | Early Intervention Provider Agency | 305R00000X | 016604 | MO | N | Managed Care Organizations | Preferred Provider Organization | 261Q00000X | 016604 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.