1154872372 NPI number — EVOLVE GROWTH INITIATIVES LLC

Table of content: (NPI 1154872372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154872372 NPI number — EVOLVE GROWTH INITIATIVES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLVE GROWTH INITIATIVES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVOLVE TREATMENT CENTERS - AGOURA HILLS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154872372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 N PACIFIC COAST HWY STE 2060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL SEGUNDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90245-4479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-361-9705
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6425 CHESEBRO ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AGOURA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-281-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LAI
Authorized Official First Name:
EDDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
772-361-9705

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3245S0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 198209044 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05D2126813 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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