Healthcare Provider Details

I. General information

NPI: 1902663834
Provider Name (Legal Business Name): EVOLVE GROWTH INITIATIVES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 EDGAR PL
LA MESA CA
91941-6833
US

IV. Provider business mailing address

360 N PACIFIC COAST HWY STE 1010
EL SEGUNDO CA
90245-4413
US

V. Phone/Fax

Practice location:
  • Phone: 424-290-3360
  • Fax:
Mailing address:
  • Phone: 424-290-3360
  • Fax: 424-290-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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: CFO
Credential:
Phone: 424-290-3360