Healthcare Provider Details

I. General information

NPI: 1932685112
Provider Name (Legal Business Name): TRANSFORMATIVE DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 N MEMPHIS ST
HOLLY SPRINGS MS
38635-2258
US

IV. Provider business mailing address

198 N MEMPHIS ST
HOLLY SPRINGS MS
38635-2258
US

V. Phone/Fax

Practice location:
  • Phone: 662-274-3089
  • Fax: 662-274-3139
Mailing address:
  • Phone: 662-274-3089
  • Fax: 662-274-3139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WALTER RAYFORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-569-7165