Healthcare Provider Details

I. General information

NPI: 1679042121
Provider Name (Legal Business Name): TRANSFORMATION THERAPEUTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 MOUNTAIN VILLAGE BLVD STE 102
MOUNTAIN VILLAGE CO
81435-9529
US

IV. Provider business mailing address

622 MOUNTAIN VILLAGE BLVD STE 102
MOUNTAIN VILLAGE CO
81435-9529
US

V. Phone/Fax

Practice location:
  • Phone: 970-728-7047
  • Fax: 970-728-7045
Mailing address:
  • Phone: 970-728-7047
  • Fax: 970-728-7045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BULLOCK
Title or Position: OWNER
Credential: PT
Phone: 214-864-2440