Healthcare Provider Details

I. General information

NPI: 1699182212
Provider Name (Legal Business Name): EVOLVE EMOD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5965 S 900 E STE 255
SALT LAKE CITY UT
84121-1872
US

IV. Provider business mailing address

5965 S 900 E STE 255
SALT LAKE CITY UT
84121-1872
US

V. Phone/Fax

Practice location:
  • Phone: 844-438-7577
  • Fax:
Mailing address:
  • Phone: 844-438-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name: ANDREW WINAKOR
Title or Position: MEMBER
Credential:
Phone: 516-807-9324