Provider Demographics
NPI:1366694705
Name:EVOLUTION SPORTS PHYSIOTHERAPY, INC.
Entity Type:Organization
Organization Name:EVOLUTION SPORTS PHYSIOTHERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:SANDFORD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPT
Authorized Official - Phone:410-628-0520
Mailing Address - Street 1:10540 YORK RD
Mailing Address - Street 2:SUITE F-G
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2300
Mailing Address - Country:US
Mailing Address - Phone:410-628-0520
Mailing Address - Fax:
Practice Address - Street 1:10540 YORK RD
Practice Address - Street 2:SUITE F-G
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2300
Practice Address - Country:US
Practice Address - Phone:410-628-0520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20554261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy