Provider Demographics
NPI:1215534805
Name:LIMITLESS EVOLUTION LLC
Entity Type:Organization
Organization Name:LIMITLESS EVOLUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESKIN
Authorized Official - Suffix:
Authorized Official - Credentials:FEDERAL GOVERNMENT
Authorized Official - Phone:573-693-9818
Mailing Address - Street 1:3524 OSAGE BEACH PKWY
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-5622
Mailing Address - Country:US
Mailing Address - Phone:573-693-9818
Mailing Address - Fax:
Practice Address - Street 1:3524 OSAGE BEACH PKWY
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-5622
Practice Address - Country:US
Practice Address - Phone:573-693-9818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
9HAHHA800OtherHIN