MEDICARE: EVOLVE GROWTH INITIATIVES LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	324500000X	Substance Abuse Rehabilitation Facility
2	3245S0500X	Children's Substance Abuse Rehabilitation Facility
3	323P00000X	Psychiatric Residential Treatment Facility
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center
5	320800000X	Mental Illness Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	075650153	OTHER	CA	CCLD

General Provider Information

NPI Number	:	1548802945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE GROWTH INITIATIVES LLC

Provider Business Mailing Address
First Line	:	360 N PACIFIC COAST HWY STE 1010
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-4413
Country	:	US
Telephone Number	:	424-290-3360
Fax Number	:	424-290-3355

Provider Business Practice Location Address
First Line	:	1261 PANORAMA DR
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-2412
Country	:	US
Telephone Number	:	855-490-0302
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	EDDY LAI
Credential	:
Telephone Number	:	424-290-3341

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	03/24/2026

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