MEDICARE: EVOLVED, 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1699245654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVED, INC.

Provider Business Mailing Address
First Line	:	10573 W PICO BLVD UNIT 414
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2333
Country	:	US
Telephone Number	:	310-927-0654
Fax Number	:

Provider Business Practice Location Address
First Line	:	10573 W PICO BLVD UNIT 414
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2333
Country	:	US
Telephone Number	:	310-927-0654
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DIANA VELASCO
Credential	:
Telephone Number	:	310-927-0654

Provider Enumeration Date	:	12/03/2018
Last Update Date	:	12/03/2018

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Directions to “EVOLVED, INC. ” Practice Location

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