Provider Demographics
NPI:1285801191
Name:THE EVOLUTION GROUP INC.
Entity type:Organization
Organization Name:THE EVOLUTION GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-242-6988
Mailing Address - Street 1:218 BROADWAY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3425
Mailing Address - Country:US
Mailing Address - Phone:505-242-6988
Mailing Address - Fax:505-242-6972
Practice Address - Street 1:218 BROADWAY BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3425
Practice Address - Country:US
Practice Address - Phone:505-242-6988
Practice Address - Fax:505-242-6972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87423251Medicaid