Provider Demographics
NPI:1679042121
Name:TRANSFORMATION THERAPEUTICS, PLLC
Entity type:Organization
Organization Name:TRANSFORMATION THERAPEUTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:214-864-2440
Mailing Address - Street 1:622 MOUNTAIN VILLAGE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-9529
Mailing Address - Country:US
Mailing Address - Phone:970-728-7047
Mailing Address - Fax:970-728-7045
Practice Address - Street 1:622 MOUNTAIN VILLAGE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:81435-9529
Practice Address - Country:US
Practice Address - Phone:970-728-7047
Practice Address - Fax:970-728-7045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy