Provider Demographics
NPI:1477286227
Name:EVOLUTION MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:EVOLUTION MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O
Authorized Official - Prefix:MR
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-851-5032
Mailing Address - Street 1:11278 LOS ALAMITOS BLVD # 719
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3958
Mailing Address - Country:US
Mailing Address - Phone:562-241-0780
Mailing Address - Fax:562-741-5889
Practice Address - Street 1:3772 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3104
Practice Address - Country:US
Practice Address - Phone:562-241-0780
Practice Address - Fax:562-741-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24918649600001OtherSELLER'S PERMIT