Provider Demographics
NPI:1598079758
Name:EVOLVE CENTER FOR FUNCTIONAL MEDICINE, LLC
Entity Type:Organization
Organization Name:EVOLVE CENTER FOR FUNCTIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HATH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-666-7685
Mailing Address - Street 1:506 W BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-1723
Mailing Address - Country:US
Mailing Address - Phone:303-666-7685
Mailing Address - Fax:
Practice Address - Street 1:506 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-1723
Practice Address - Country:US
Practice Address - Phone:303-666-7685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR6544111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty