Provider Demographics
NPI:1770951980
Name:EVOLUTION HEALTHCARE MANAGEMENT LLC
Entity type:Organization
Organization Name:EVOLUTION HEALTHCARE MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAWN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BOONSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-286-7907
Mailing Address - Street 1:99 S GOLD DR STE 6
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-5036
Mailing Address - Country:US
Mailing Address - Phone:480-354-7878
Mailing Address - Fax:949-577-4159
Practice Address - Street 1:7615 E BASELINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-8520
Practice Address - Country:US
Practice Address - Phone:480-354-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2300X, 261QP2300X, 261QS1200X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty