MEDICARE: EVOLUTION HEALTHCARE INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	ME91433	FL

General Provider Information

NPI Number	:	1417371436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLUTION HEALTHCARE INC

Provider Business Mailing Address
First Line	:	2450 SW 137TH AVE STE 206
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6312
Country	:	US
Telephone Number	:	786-660-2433
Fax Number	:	305-551-1121

Provider Business Practice Location Address
First Line	:	2450 SW 137TH AVE STE 206
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6312
Country	:	US
Telephone Number	:	786-660-2433
Fax Number	:	305-551-1121

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	LUIS LOPEZ MAS
Credential	:	MD
Telephone Number	:	786-660-2433

Provider Enumeration Date	:	02/11/2014
Last Update Date	:	02/11/2014

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