MEDICARE: EVITA MED SPA

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1598560625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVITA MED SPA

Provider Business Mailing Address
First Line	:	313 NORTON DR STE 101
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5965
Country	:	US
Telephone Number	:	850-583-7661
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 NORTON DR STE 101
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5965
Country	:	US
Telephone Number	:	850-583-7661
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPS
Name	:	ANTHONY DELGADO
Credential	:	NP
Telephone Number	:	305-747-0000

Provider Enumeration Date	:	02/13/2025
Last Update Date	:	02/13/2025

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Directions to “EVITA MED SPA ” Practice Location

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