Provider Demographics
NPI:1093736225
Name:EVOLUTION ALTERNATIVE PHYSICAL THERAPY & WELLNESS STUDIO LLC
Entity Type:Organization
Organization Name:EVOLUTION ALTERNATIVE PHYSICAL THERAPY & WELLNESS STUDIO LLC
Other - Org Name:EVOLUTION PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE. PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-944-6535
Mailing Address - Street 1:2510 7TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2004
Mailing Address - Country:US
Mailing Address - Phone:814-944-6535
Mailing Address - Fax:814-944-6545
Practice Address - Street 1:2510 7TH AVENUE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2004
Practice Address - Country:US
Practice Address - Phone:814-944-6535
Practice Address - Fax:814-944-6545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012999L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018563450006Medicaid
PA103712991-0001Medicaid
PAP00314995OtherPALMETTO GBA