Provider Demographics
NPI:1811410343
Name:TRANSFORMATION 360 LLC
Entity Type:Organization
Organization Name:TRANSFORMATION 360 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:DELIA
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-628-1223
Mailing Address - Street 1:2801 N RAINBOW BLVD APT 212
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4583
Mailing Address - Country:US
Mailing Address - Phone:702-628-1223
Mailing Address - Fax:
Practice Address - Street 1:2801 N RAINBOW BLVD APT 212
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4583
Practice Address - Country:US
Practice Address - Phone:702-628-1223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health