Provider Demographics
NPI:1245015759
Name:EVOLVE HYDRATION AND WELLNESS LLC
Entity type:Organization
Organization Name:EVOLVE HYDRATION AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:407-353-1336
Mailing Address - Street 1:187 SABAL PALM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-2595
Mailing Address - Country:US
Mailing Address - Phone:407-353-1336
Mailing Address - Fax:
Practice Address - Street 1:187 SABAL PALM DR STE 100
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2595
Practice Address - Country:US
Practice Address - Phone:407-353-1336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service