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General NPI Number Information
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NPI Number | 1376161380
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Entity Type | Organization
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Legal Business Name | EVOLUTION HEALTH & PERFORMANCE LLC
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Dates
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Enumeration Date | 07/07/2020
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Last Update Date | 07/07/2020
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Provider Practice Location Address
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Address Line | 244 S. PALMETTO AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32114
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Country | US
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Telephone | 386-310-2385
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Fax | 386-233-9488
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Provider Business Mailing Address
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Address Line | 244 S. PALMETTO AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32114
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Country | US
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Telephone | 386-310-2385
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Fax | 386-233-9488
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Authorized Official
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Title or Position | OWNER/PA
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Name | BOBBY JOHN ARDILA
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Credential | PA
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Telephone | 407-739-2395
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number |
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License Number State |
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