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General NPI Number Information
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NPI Number | 1366989808
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Entity Type | Organization
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Legal Business Name | EVOLVEGENE, LLC
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Dates
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Enumeration Date | 01/23/2017
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Last Update Date | 01/23/2017
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Provider Practice Location Address
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Address Line | 12105 28TH ST N UNIT A
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City | SAINT PETERSBURG
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State | FL
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Zip | 33716-1817
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Country | US
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Telephone | 727-623-4052
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Fax | 727-202-8148
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Provider Business Mailing Address
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Address Line | 12105 28TH ST N UNIT A
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City | SAINT PETERSBURG
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State | FL
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Zip | 33716-1817
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Country | US
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Telephone | 727-623-4052
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Fax | 727-202-8148
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MIKE CECCHI
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Credential |
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Telephone | 203-641-5622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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