Healthcare Provider Details

I. General information

NPI: 1942832001
Provider Name (Legal Business Name): TRANSFORMED FOR LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 OSUNA RD NE STE 201
ALBUQUERQUE NM
87107-5950
US

IV. Provider business mailing address

316 OSUNA RD NE STE 201
ALBUQUERQUE NM
87107-5950
US

V. Phone/Fax

Practice location:
  • Phone: 505-343-2010
  • Fax: 505-247-8881
Mailing address:
  • Phone: 505-343-2010
  • Fax: 505-247-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JACLYN ARMIJO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 505-343-2010