Provider Demographics
NPI:1326691866
Name:EVOLVE PEDIATRIC LLC
Entity Type:Organization
Organization Name:EVOLVE PEDIATRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-443-9749
Mailing Address - Street 1:10250 SW 56TH ST STE C203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-7098
Mailing Address - Country:US
Mailing Address - Phone:786-443-9749
Mailing Address - Fax:
Practice Address - Street 1:10250 SW 56TH ST STE C203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7098
Practice Address - Country:US
Practice Address - Phone:786-443-9749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center