Healthcare Provider Details

I. General information

NPI: 1215256045
Provider Name (Legal Business Name): EVOLUTION FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 RIDGECREST RD
EDMOND OK
73013-6653
US

IV. Provider business mailing address

1620 RIDGECREST RD
EDMOND OK
73013-6653
US

V. Phone/Fax

Practice location:
  • Phone: 405-203-7898
  • Fax:
Mailing address:
  • Phone: 405-330-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF TALLENT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 405-203-7898