Provider Demographics
NPI:1043626724
Name:EVOLVE OCCUPATIONAL & PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:EVOLVE OCCUPATIONAL & PHYSICAL THERAPY P.C.
Other - Org Name:EVOLVE THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KENUK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:856-220-1460
Mailing Address - Street 1:11490 BRADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5151
Mailing Address - Country:US
Mailing Address - Phone:856-220-1460
Mailing Address - Fax:855-330-1292
Practice Address - Street 1:11490 BRADDOCK DR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5151
Practice Address - Country:US
Practice Address - Phone:856-220-1460
Practice Address - Fax:855-330-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy