Provider Demographics
NPI:1316256555
Name:TRANSFORMATIVE LIFE CENTER, LLC.
Entity type:Organization
Organization Name:TRANSFORMATIVE LIFE CENTER, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-747-5520
Mailing Address - Street 1:3440 TORINGDON WAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3190
Mailing Address - Country:US
Mailing Address - Phone:877-747-5520
Mailing Address - Fax:877-539-5520
Practice Address - Street 1:3440 TORINGDON WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3190
Practice Address - Country:US
Practice Address - Phone:877-747-5520
Practice Address - Fax:877-539-5520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRANSFORMATIVE LIFE CENTER, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty