MEDICARE: TRANSFORMATION 180

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

General Provider Information

NPI Number	:	1972930709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSFORMATION 180

Provider Business Mailing Address
First Line	:	6500 W CHARLESTON BLVD
Second Line	:	421
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9054
Country	:	US
Telephone Number	:	702-776-6541
Fax Number	:

Provider Business Practice Location Address
First Line	:	1555 E FLAMINGO RD
Second Line	:	155
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5258
Country	:	US
Telephone Number	:	702-743-1999
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ALICE DELIA HENRY
Credential	:
Telephone Number	:	562-507-2966

Provider Enumeration Date	:	10/11/2013
Last Update Date	:	10/11/2013

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Directions to “TRANSFORMATION 180 ” Practice Location

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