Healthcare Provider Details

I. General information

NPI: 1417216821
Provider Name (Legal Business Name): EVOLUTION HOLISTIC HEALTHCARE, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 S BEVERLY DR STE 110
BEVERLY HILLS CA
90212-3851
US

IV. Provider business mailing address

269 S BEVERLY DR STE 110
BEVERLY HILLS CA
90212-3851
US

V. Phone/Fax

Practice location:
  • Phone: 424-254-9622
  • Fax:
Mailing address:
  • Phone: 424-254-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC10770
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33660
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number34748
License Number StateCA

VIII. Authorized Official

Name: MR. AARON BULLOCK
Title or Position: OWNER
Credential:
Phone: 424-254-9622