Provider Demographics
NPI:1477095768
Name:LET YOUR SOUL EVOLVE, LLC.
Entity Type:Organization
Organization Name:LET YOUR SOUL EVOLVE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJARAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-272-6612
Mailing Address - Street 1:4723 W ATLANTIC AVE
Mailing Address - Street 2:SUITE A-11
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-3895
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4723 W ATLANTIC AVE
Practice Address - Street 2:SUITE A-21
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-3895
Practice Address - Country:US
Practice Address - Phone:561-628-6651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness