Healthcare Provider Details

I. General information

NPI: 1538992540
Provider Name (Legal Business Name): EVOLVE ANTI-AGING & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16500 VENTURA BLVD STE 420
ENCINO CA
91436-2062
US

IV. Provider business mailing address

16500 VENTURA BLVD STE 420
ENCINO CA
91436-2062
US

V. Phone/Fax

Practice location:
  • Phone: 818-600-7600
  • Fax: 818-334-2497
Mailing address:
  • Phone: 818-600-7600
  • Fax: 818-334-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANI ZAGHIKIAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 818-606-2459