MEDICARE: EVOLVE WELLNESS & IV HYDRATION CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
3	363LA2200X	Adult Health Nurse Practitioner
4	363LP2300X	Primary Care Nurse Practitioner
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1265142780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE WELLNESS & IV HYDRATION CENTER LLC

Provider Business Mailing Address
First Line	:	5330 HEATHERDOWNS BLVD STE 207
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-4644
Country	:	US
Telephone Number	:	419-314-9535
Fax Number	:	419-469-5495

Provider Business Practice Location Address
First Line	:	5330 HEATHERDOWNS BLVD STE 207
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-4644
Country	:	US
Telephone Number	:	419-314-9535
Fax Number	:	419-469-5495

Authorized Official
Title or Position	:	NP-C
Name	:	TAMESHIA WIGGINS
Credential	:	APRN
Telephone Number	:	419-314-9535

Provider Enumeration Date	:	11/28/2022
Last Update Date	:	11/19/2024

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