Provider Demographics
NPI:1508049099
Name:EVOLUTION PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:EVOLUTION PHYSICAL THERAPY, INC
Other - Org Name:BEBE PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGT
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:310-305-7100
Mailing Address - Street 1:322 CULVER BLVD
Mailing Address - Street 2:207
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7704
Mailing Address - Country:US
Mailing Address - Phone:310-305-7100
Mailing Address - Fax:310-305-7101
Practice Address - Street 1:11901 SANTA MONICA BLVD
Practice Address - Street 2:202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2767
Practice Address - Country:US
Practice Address - Phone:310-479-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty