1568197416 NPI number — EVOLUCION OF WELLNESS LLC

Table of content: (NPI 1568197416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568197416 NPI number — EVOLUCION OF WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUCION OF WELLNESS 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:
1568197416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1129 RIVERDALE ST # 1019
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01089-4615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-426-1321
Provider Business Mailing Address Fax Number:
413-238-6461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 MAPLE ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01105-1896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-225-1197
Provider Business Practice Location Address Fax Number:
413-238-6461
Provider Enumeration Date:
07/22/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
ILEANA
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
413-426-1321

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1891049664 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".