Provider Demographics
NPI:1710779905
Name:EPIC TRANSFORMATION WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:EPIC TRANSFORMATION WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ILLYAS
Authorized Official - Middle Name:MALIK
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:QMHA
Authorized Official - Phone:954-380-0875
Mailing Address - Street 1:8904 TRICKLING SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-2991
Mailing Address - Country:US
Mailing Address - Phone:954-380-0875
Mailing Address - Fax:
Practice Address - Street 1:2620 REGATTA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-6891
Practice Address - Country:US
Practice Address - Phone:954-380-0875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty