Provider Demographics
NPI:1114480183
Name:EVOLVE FLAGSTAFF LLC
Entity Type:Organization
Organization Name:EVOLVE FLAGSTAFF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:928-326-0316
Mailing Address - Street 1:123 W BIRCH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4508
Mailing Address - Country:US
Mailing Address - Phone:928-793-6237
Mailing Address - Fax:928-366-5976
Practice Address - Street 1:123 W BIRCH AVE STE 100
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4508
Practice Address - Country:US
Practice Address - Phone:928-793-6237
Practice Address - Fax:928-366-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty