Provider Demographics
NPI:1366624512
Name:EVOLUTION CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:EVOLUTION CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEB
Authorized Official - Middle Name:
Authorized Official - Last Name:THURMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:603-313-0617
Mailing Address - Street 1:640 MARLBORO ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-4049
Mailing Address - Country:US
Mailing Address - Phone:603-338-0231
Mailing Address - Fax:855-461-4277
Practice Address - Street 1:640 MARLBORO ST STE 1
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-4049
Practice Address - Country:US
Practice Address - Phone:603-313-0617
Practice Address - Fax:603-461-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH180-0494111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHEVRE7051Medicare PIN