Healthcare Provider Details

I. General information

NPI: 1669985867
Provider Name (Legal Business Name): EVOLVE GROWTH INITIATIVES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 BUTCH DR
GILROY CA
95020
US

IV. Provider business mailing address

300 N PACIFIC COAST HWY STE 2060
EL SEGUNDO CA
90245-4479
US

V. Phone/Fax

Practice location:
  • Phone: 424-281-5000
  • Fax:
Mailing address:
  • Phone: 772-361-9705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: EDDY LAI
Title or Position: CONTROLLER
Credential:
Phone: 772-361-9705