Provider Demographics
NPI:1265142780
Name:EVOLVE WELLNESS & IV HYDRATION CENTER LLC
Entity type:Organization
Organization Name:EVOLVE WELLNESS & IV HYDRATION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NP-C
Authorized Official - Prefix:
Authorized Official - First Name:TAMESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:419-314-9535
Mailing Address - Street 1:5330 HEATHERDOWNS BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4644
Mailing Address - Country:US
Mailing Address - Phone:419-314-9535
Mailing Address - Fax:419-469-5495
Practice Address - Street 1:5330 HEATHERDOWNS BLVD STE 207
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-4644
Practice Address - Country:US
Practice Address - Phone:419-314-9535
Practice Address - Fax:419-469-5495
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVOLVE WELLNESS & IV HYDRATION CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-28
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty