Healthcare Provider Details

I. General information

NPI: 1245015759
Provider Name (Legal Business Name): EVOLVE HYDRATION AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 SABAL PALM DR STE 100
LONGWOOD FL
32779-2595
US

IV. Provider business mailing address

187 SABAL PALM DR STE 100
LONGWOOD FL
32779-2595
US

V. Phone/Fax

Practice location:
  • Phone: 407-353-1336
  • Fax:
Mailing address:
  • Phone: 407-353-1336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAMEKA CAMPBELL
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 407-353-1336