Healthcare Provider Details

I. General information

NPI: 1376161380
Provider Name (Legal Business Name): EVOLUTION HEALTH & PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 S. PALMETTO AVE
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

244 S. PALMETTO AVE
DAYTONA BEACH FL
32114
US

V. Phone/Fax

Practice location:
  • Phone: 386-310-2385
  • Fax: 386-233-9488
Mailing address:
  • Phone: 386-310-2385
  • Fax: 386-233-9488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BOBBY JOHN ARDILA
Title or Position: OWNER/PA
Credential: PA
Phone: 407-739-2395