Healthcare Provider Details

I. General information

NPI: 1548699606
Provider Name (Legal Business Name): EVOLVES VASCULAR LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 STERTHAUS DR
ORMOND BEACH FL
32174-5128
US

IV. Provider business mailing address

588 STERTHAUS DR
ORMOND BEACH FL
32174-5128
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-9501
  • Fax: 386-673-0308
Mailing address:
  • Phone: 386-672-9501
  • Fax: 386-673-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number58979
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number58979
License Number StateFL

VIII. Authorized Official

Name: VICKY BROWNING
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-672-9501