1548721186 NPI number — EVOLVE GROWTH INITIATIVES, LLC

Table of content: (NPI 1548721186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548721186 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 - DANVILLE
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:
1548721186
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:
424-290-3341
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 MONTEGO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94526-4842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-290-3341
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2019

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)





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