Provider Demographics
NPI:1689005126
Name:RUSH, EVAN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:MICHAEL
Last Name:RUSH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 N WICKHAM RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8012
Mailing Address - Country:US
Mailing Address - Phone:321-253-8511
Mailing Address - Fax:321-253-8711
Practice Address - Street 1:2255 N WICKHAM RD
Practice Address - Street 2:SUITE 109
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8012
Practice Address - Country:US
Practice Address - Phone:321-253-8511
Practice Address - Fax:321-253-8711
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10891111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor