Provider Demographics
NPI:1619476801
Name:EVOLVED SOURCE SOLUTIONS CORP
Entity Type:Organization
Organization Name:EVOLVED SOURCE SOLUTIONS CORP
Other - Org Name:ESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-288-9470
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33970-0516
Mailing Address - Country:US
Mailing Address - Phone:239-288-9470
Mailing Address - Fax:
Practice Address - Street 1:8411 HERON POND DR APT B110
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-8548
Practice Address - Country:US
Practice Address - Phone:239-288-9470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP52-541-79-263-0171R00000X, 343800000X, 343900000X, 347C00000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation BrokerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP532-541-79-263-0OtherFLLICENSE