Provider Demographics
NPI:1346579869
Name:EVOLUTION THERAPEUTICS LLC
Entity Type:Organization
Organization Name:EVOLUTION THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MULCAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:503-956-6686
Mailing Address - Street 1:11930 SW GREENBURG RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6453
Mailing Address - Country:US
Mailing Address - Phone:503-956-6686
Mailing Address - Fax:
Practice Address - Street 1:11930 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6453
Practice Address - Country:US
Practice Address - Phone:503-956-6686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1006876261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center