Provider Demographics
NPI:1851847297
Name:EVOLUTION HAIR CARE,LLC
Entity Type:Organization
Organization Name:EVOLUTION HAIR CARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HAIR LOSS SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRON
Authorized Official - Middle Name:JANEAN
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-501-6402
Mailing Address - Street 1:12429 PITTSBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6000
Mailing Address - Country:US
Mailing Address - Phone:405-501-6402
Mailing Address - Fax:
Practice Address - Street 1:11102 STRATFORD DR STE B200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7263
Practice Address - Country:US
Practice Address - Phone:405-501-6402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK94711251B00000X, 302F00000X, 305R00000X, 305S00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No251B00000XAgenciesCase Management
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment