Organization
EVOLVE LIFE CENTERS IOP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JESSIE COSTLEY (ADMINISTRATOR)
(443) 548-3733
Entity
Organization
Contact information
Practice address
2528 MOUNTAIN RD, SUITE 102-103 AND 201-204, PASADENA, MD 21122-7203
(443) 548-3733
(410) 360-1675
Mailing address
2528 MOUNTAIN RD, PASADENA, MD 21122-7203
(410) 456-7404
(410) 360-1675
Taxonomy
Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
324500000X
Substance Abuse Rehabilitation Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200319800
—
MD
Enumeration date
01/31/2017
Last updated
06/14/2024
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