MEDICARE: 1 TLC:TRANSFORMATIVE LIFE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253J00000X	Foster Care Agency		TX

General Provider Information

NPI Number	:	1164896122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1 TLC:TRANSFORMATIVE LIFE CENTER

Provider Business Mailing Address
First Line	:	1229 E PLEASANT RUN RD STE 124
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-4211
Country	:	US
Telephone Number	:	469-774-3053
Fax Number	:

Provider Business Practice Location Address
First Line	:	1229 E PLEASANT RUN RD
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-4209
Country	:	US
Telephone Number	:	469-774-3053
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DEMETRA DONALDSON
Credential	:
Telephone Number	:	469-774-3053

Provider Enumeration Date	:	11/13/2015
Last Update Date	:	11/13/2015

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