Provider Demographics
NPI:1275072936
Name:EVOLUTION WELLNESS
Entity Type:Organization
Organization Name:EVOLUTION WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITOL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:773-368-8682
Mailing Address - Street 1:7700 N CAPITAL OF TEXAS HWY
Mailing Address - Street 2:726
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1183
Mailing Address - Country:US
Mailing Address - Phone:773-368-8682
Mailing Address - Fax:
Practice Address - Street 1:7700 N CAPITAL OF TEXAS HWY
Practice Address - Street 2:726
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1183
Practice Address - Country:US
Practice Address - Phone:773-368-8682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1235920261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy