Provider Demographics
NPI:1215493978
Name:TRANSFORMATION CENTER-CLEVELAND
Entity type:Organization
Organization Name:TRANSFORMATION CENTER-CLEVELAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-499-9335
Mailing Address - Street 1:7209 HAMILTON ACRES CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-8623
Mailing Address - Country:US
Mailing Address - Phone:423-499-9335
Mailing Address - Fax:423-499-9334
Practice Address - Street 1:423 CENTRAL AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-4923
Practice Address - Country:US
Practice Address - Phone:423-476-1933
Practice Address - Fax:423-559-1848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRANSFORMATION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000000023616OtherSTATE LICENSE