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General NPI Number Information
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NPI Number | 1821768649
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Entity Type | Organization
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Legal Business Name | EVO BODY IMAGE, LLC
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Dates
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Enumeration Date | 09/14/2021
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Last Update Date | 09/14/2021
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Provider Practice Location Address
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Address Line | 950 E MAPLE RD STE L10
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City | BIRMINGHAM
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State | MI
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Zip | 48009-6482
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Country | US
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Telephone | 248-595-2363
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Fax |
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Provider Business Mailing Address
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Address Line | 6642 LEYTONSTONE BLVD
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-1200
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ORGANIZER
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Name | SIDRA S ELIA
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Credential | MD
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Telephone | 248-595-2363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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