=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932815164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANSFORMATIVE WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2023
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 454 S YONGE ST STE 3A
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-7501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-280-4877
-----------------------------------------------------
Fax | 386-414-7227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 454 S YONGE ST STE 3A
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-7501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-280-4877
-----------------------------------------------------
Fax | 386-414-7227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN
-----------------------------------------------------
Name | MRS. CASIE MCCALLISTER
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 386-280-4877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------