Provider Demographics
NPI:1972930709
Name:TRANSFORMATION 180
Entity Type:Organization
Organization Name:TRANSFORMATION 180
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:DELIA
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-507-2966
Mailing Address - Street 1:6500 W CHARLESTON BLVD
Mailing Address - Street 2:421
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-9054
Mailing Address - Country:US
Mailing Address - Phone:702-776-6541
Mailing Address - Fax:
Practice Address - Street 1:1555 E FLAMINGO RD
Practice Address - Street 2:155
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5258
Practice Address - Country:US
Practice Address - Phone:702-743-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health