Healthcare Provider Details

I. General information

NPI: 1457946485
Provider Name (Legal Business Name): HEALTH&LIFE EVOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14047 WALCOTT AVE
ORLANDO FL
32827-7471
US

IV. Provider business mailing address

14047 WALCOTT AVE
ORLANDO FL
32827-7471
US

V. Phone/Fax

Practice location:
  • Phone: 407-272-8505
  • Fax:
Mailing address:
  • Phone: 407-272-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JOEL JOSUE VALLENILLA
Title or Position: PRESIDENT
Credential: SA-C
Phone: 407-272-8505