=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528428372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH & WELLNESS EVOLUTION CO.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2016
-----------------------------------------------------
Last Update Date | 04/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6905 NW 77TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-717-7656
-----------------------------------------------------
Fax | 786-254-7439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6905 NW 77TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-717-7656
-----------------------------------------------------
Fax | 786-254-7439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MIGUEL RIOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-717-7656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | HCC10565
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------