MEDICARE: TRANSFORMING 2 GREATNESS, LLC

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	251S00000X	Community/Behavioral Health Agency	20121134253	NV

General Provider Information

NPI Number	:	1225395148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSFORMING 2 GREATNESS, LLC

Provider Business Mailing Address
First Line	:	2616 SLIDE CANYON AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6411
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2616 SLIDE CANYON AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6411
Country	:	US
Telephone Number	:	702-501-8633
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MS. RADESA WADE
Credential	:
Telephone Number	:	702-501-8633

Provider Enumeration Date	:	04/16/2012
Last Update Date	:	04/16/2012

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