Provider Demographics
NPI:1285006403
Name:EVOLUTION CHIROPRACTIC
Entity Type:Organization
Organization Name:EVOLUTION CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BENCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-552-9600
Mailing Address - Street 1:1410 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6269
Mailing Address - Country:US
Mailing Address - Phone:208-552-9600
Mailing Address - Fax:
Practice Address - Street 1:1410 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6269
Practice Address - Country:US
Practice Address - Phone:208-552-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1393111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty