Healthcare Provider Details

I. General information

NPI: 1487279014
Provider Name (Legal Business Name): EVOLVE YOGA & FITNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7252 W FOSTER AVE
CHICAGO IL
60656-3612
US

IV. Provider business mailing address

5115 N MULLIGAN AVE
CHICAGO IL
60630-1812
US

V. Phone/Fax

Practice location:
  • Phone: 708-762-3362
  • Fax:
Mailing address:
  • Phone: 773-318-7820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. CURTIS EVRARD
Title or Position: OWNER
Credential: OWNER
Phone: 773-318-7820