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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |