Provider Demographics
NPI:1851740898
Name:EVOLUTION WAY
Entity Type:Organization
Organization Name:EVOLUTION WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-438-4357
Mailing Address - Street 1:724 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5649
Mailing Address - Country:US
Mailing Address - Phone:480-438-4357
Mailing Address - Fax:
Practice Address - Street 1:724 W UNIVERSITY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5649
Practice Address - Country:US
Practice Address - Phone:480-438-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder