Healthcare Provider Details

I. General information

NPI: 1376458133
Provider Name (Legal Business Name): EXCELLENT EVOLUTION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 TECH BLVD
TAMPA FL
33619-7865
US

IV. Provider business mailing address

1404 TECH BLVD
TAMPA FL
33619-7865
US

V. Phone/Fax

Practice location:
  • Phone: 813-424-8896
  • Fax: 813-533-6791
Mailing address:
  • Phone: 813-424-8896
  • Fax: 813-533-6791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHARLES G. RIVERA-MARTINEZ
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 813-424-8896