MEDICARE: EVOLVE WELLNESS 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	1041C0700X	Clinical Social Worker
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1699406769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE WELLNESS LLC

Provider Business Mailing Address
First Line	:	3430 E FLAMINGO RD STE 309
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5066
Country	:	US
Telephone Number	:	702-427-9040
Fax Number	:

Provider Business Practice Location Address
First Line	:	3430 E FLAMINGO RD STE 309
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5066
Country	:	US
Telephone Number	:	725-204-2578
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MADELEINE NAVARRO DIAZ
Credential	:
Telephone Number	:	725-204-2578

Provider Enumeration Date	:	06/20/2022
Last Update Date	:	05/22/2023

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Directions to “EVOLVE WELLNESS LLC ” Practice Location

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