Provider Demographics
NPI:1376161380
Name:EVOLUTION HEALTH & PERFORMANCE LLC
Entity Type:Organization
Organization Name:EVOLUTION HEALTH & PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PA
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ARDILA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:407-739-2395
Mailing Address - Street 1:244 S. PALMETTO AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-310-2385
Mailing Address - Fax:386-233-9488
Practice Address - Street 1:244 S. PALMETTO AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-310-2385
Practice Address - Fax:386-233-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty