Provider Demographics
NPI:1043924319
Name:EVOLVE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:EVOLVE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:309-287-2526
Mailing Address - Street 1:2691 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3838
Mailing Address - Country:US
Mailing Address - Phone:414-840-9409
Mailing Address - Fax:
Practice Address - Street 1:2691 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-3838
Practice Address - Country:US
Practice Address - Phone:414-840-9409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy