MEDICARE: EVOLVE NUTRITION 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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1942906003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE NUTRITION LLC

Provider Business Mailing Address
First Line	:	1612 U ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-6221
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 U ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-6221
Country	:	US
Telephone Number	:	434-242-6664
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	RACHEL LEACH
Credential	:	MS, RD
Telephone Number	:	434-242-6664

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	02/07/2023

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