MEDICARE: EVOLUTION ACADEMY OF UTAH LLC

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	323P00000X	Psychiatric Residential Treatment Facility	11353	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558432849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLUTION ACADEMY OF UTAH LLC

Provider Business Mailing Address
First Line	:	1144 W 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84119-7175
Country	:	US
Telephone Number	:	801-433-2900
Fax Number	:	801-433-2999

Provider Business Practice Location Address
First Line	:	1144 W 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84119-7175
Country	:	US
Telephone Number	:	801-433-2900
Fax Number	:	801-433-2999

Authorized Official
Title or Position	:	C.E.O.
Name	:	MR. JAMES BAILEY
Credential	:
Telephone Number	:	801-433-2900

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	08/22/2020

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