Healthcare Provider Details

I. General information

NPI: 1285801191
Provider Name (Legal Business Name): THE EVOLUTION GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

IV. Provider business mailing address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6988
  • Fax: 505-242-6972
Mailing address:
  • Phone: 505-242-6988
  • Fax: 505-242-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL BLACKWOOD
Title or Position: DIRECTOR
Credential: LPCC
Phone: 505-242-6988