1770951980 NPI number — EVOLUTION HEALTHCARE MANAGEMENT LLC

Table of content: (NPI 1770951980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770951980 NPI number — EVOLUTION HEALTHCARE MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUTION HEALTHCARE MANAGEMENT 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:
EVOLUTION MANAGEMENT SERVICES COMPANY
Provider Other Organization Name Type Code:
4
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:
1770951980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 S GOLD DR STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APACHE JUNCTION
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85120-5036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-354-7878
Provider Business Mailing Address Fax Number:
949-577-4159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7615 E BASELINE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85209-8520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-354-7878
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BOONSTRA
Authorized Official First Name:
FAWN
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
PRESIDENT, MANAGER
Authorized Official Telephone Number:
480-286-7907

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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