MEDICARE: EVOLVE HYDRATION AND WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1245015759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE HYDRATION AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	187 SABAL PALM DR STE 100
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-2595
Country	:	US
Telephone Number	:	407-353-1336
Fax Number	:

Provider Business Practice Location Address
First Line	:	187 SABAL PALM DR STE 100
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-2595
Country	:	US
Telephone Number	:	407-353-1336
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CAMEKA CAMPBELL
Credential	:	NURSE PRACTITIONER
Telephone Number	:	407-353-1336

Provider Enumeration Date	:	08/31/2023
Last Update Date	:	08/31/2023

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