Provider Demographics
NPI:1811249758
Name:TRANSFORM DIET AND WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:TRANSFORM DIET AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MISS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:APNP
Authorized Official - Phone:262-746-9088
Mailing Address - Street 1:1231 GEORGE TOWNE DR STE B
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-2757
Mailing Address - Country:US
Mailing Address - Phone:262-746-9088
Mailing Address - Fax:262-746-9087
Practice Address - Street 1:1231 GEORGE TOWNE DR STE B
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2757
Practice Address - Country:US
Practice Address - Phone:262-746-9088
Practice Address - Fax:262-746-9087
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN VEIN CENTER AND MEDISPA, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty