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Organization

LIMITLESS EVOLUTION LLC

Active
Organization subpart
No

Provider details

NPI number
Authorized official
MR. JUSTIN DESKIN FEDERAL GOVERNMENT (OWNER)
(573) 693-9818
Entity
Organization

Contact information

Practice address
3524 OSAGE BEACH PKWY, OSAGE BEACH, MO 65065-5622
(573) 693-9818
Mailing address
3524 OSAGE BEACH PKWY, OSAGE BEACH, MO 65065-5622
(573) 693-9818

Taxonomy

Speciality
Code
Description
License number
State
171W00000X
Contractor
261Q00000X
Clinic/Center
261QM1100X
Military/U.S. Coast Guard Outpatient Clinic/Center
332B00000X
Durable Medical Equipment & Medical Supplies
Primary

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
9HAHHA800
HIN
Enumeration date
10/06/2020
Last updated
10/06/2020
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