Provider Demographics
NPI:1760189443
Name:EVOLVE 865
Entity Type:Organization
Organization Name:EVOLVE 865
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:DYVON
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:865-384-4865
Mailing Address - Street 1:244 WARREN COVE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-3986
Mailing Address - Country:US
Mailing Address - Phone:865-384-4865
Mailing Address - Fax:
Practice Address - Street 1:460 MEDICAL PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-6469
Practice Address - Country:US
Practice Address - Phone:865-384-4865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center