Provider Demographics
NPI:1609582782
Name:PURPOSELY EVOLVING
Entity Type:Organization
Organization Name:PURPOSELY EVOLVING
Other - Org Name:PURPOSELY EVOLVING MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:727-937-6060
Mailing Address - Street 1:1810 S PINELLAS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-1989
Mailing Address - Country:US
Mailing Address - Phone:727-937-6060
Mailing Address - Fax:727-937-6030
Practice Address - Street 1:1810 S PINELLAS AVE STE B
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-1989
Practice Address - Country:US
Practice Address - Phone:727-937-6060
Practice Address - Fax:727-937-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1083178040OtherNPI
FL1013086917OtherNPI