Healthcare Provider Details

I. General information

NPI: 1801523675
Provider Name (Legal Business Name): EVOLVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 MAIN ST
MARLBOROUGH NH
03455-3102
US

IV. Provider business mailing address

449 MAIN ST
MARLBOROUGH NH
03455-3102
US

V. Phone/Fax

Practice location:
  • Phone: 603-562-7310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: GAIL ALIBOZEK
Title or Position: HEALTH AND WELLNESS PRACTITIONER
Credential:
Phone: 603-562-7310