Provider Demographics
NPI:1316397193
Name:EVOLUTION CHIROPRACTIC
Entity Type:Organization
Organization Name:EVOLUTION CHIROPRACTIC
Other - Org Name:BACK 2 BACK CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-391-2771
Mailing Address - Street 1:1705 MOUNT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4261
Mailing Address - Country:US
Mailing Address - Phone:770-391-2771
Mailing Address - Fax:
Practice Address - Street 1:1705 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4261
Practice Address - Country:US
Practice Address - Phone:770-391-2771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009707111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831563469OtherNPI