1568994887 NPI number — EVOLUTIONS HEALTH GROUP LLC

Table of content: (NPI 1568994887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568994887 NPI number — EVOLUTIONS HEALTH GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUTIONS HEALTH GROUP 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:
Provider Other Organization Name Type Code:
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:
1568994887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 S DIXIE HWY
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
LANTANA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33462-4652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-619-5858
Provider Business Mailing Address Fax Number:
561-828-3154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 S DIXIE HWY
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
LANTANA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33462-4652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-619-5858
Provider Business Practice Location Address Fax Number:
561-828-3154
Provider Enumeration Date:
03/28/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
VERONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
954-203-3584

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084A0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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