Provider Demographics
NPI:1265033989
Name:EVOLVE GROWTH INITIATIVES LLC
Entity Type:Organization
Organization Name:EVOLVE GROWTH INITIATIVES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-290-3341
Mailing Address - Street 1:300 N PACIFIC COAST HWY STE 2060
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:588 SAN RAMON VALLEY BLVD, UNIT B/SUITE 110
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526
Practice Address - Country:US
Practice Address - Phone:424-290-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVOLVE GROWTH INITIATIVES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health