Provider Demographics
NPI:1568053742
Name:EVOLUTION PHYSICAL THERAPY & WELLNESS
Entity Type:Organization
Organization Name:EVOLUTION PHYSICAL THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-205-9538
Mailing Address - Street 1:130 W BERRYHILL DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5835
Mailing Address - Country:US
Mailing Address - Phone:530-205-9538
Mailing Address - Fax:
Practice Address - Street 1:130 W BERRYHILL DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5835
Practice Address - Country:US
Practice Address - Phone:530-205-9538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty