Provider Demographics
NPI:1356001804
Name:EVOLUTION SKINCARE STUDIO
Entity type:Organization
Organization Name:EVOLUTION SKINCARE STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-779-1687
Mailing Address - Street 1:24777 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3065
Mailing Address - Country:US
Mailing Address - Phone:313-779-1687
Mailing Address - Fax:
Practice Address - Street 1:24777 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3065
Practice Address - Country:US
Practice Address - Phone:313-779-1687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVOLUTION SKINCARE STUDIO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-25
Last Update Date:2021-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)