Provider Demographics
NPI:1366989808
Name:EVOLVEGENE, LLC
Entity type:Organization
Organization Name:EVOLVEGENE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CECCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-641-5622
Mailing Address - Street 1:12105 28TH ST N
Mailing Address - Street 2:UNIT A
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1817
Mailing Address - Country:US
Mailing Address - Phone:727-623-4052
Mailing Address - Fax:727-202-8148
Practice Address - Street 1:12105 28TH ST N
Practice Address - Street 2:UNIT A
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1817
Practice Address - Country:US
Practice Address - Phone:727-623-4052
Practice Address - Fax:727-202-8148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory