Provider Demographics
NPI:1922124148
Name:EVANS CHIROPRACTIC PSC
Entity Type:Organization
Organization Name:EVANS CHIROPRACTIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VENESSA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-459-4150
Mailing Address - Street 1:3071 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2101
Mailing Address - Country:US
Mailing Address - Phone:502-459-4150
Mailing Address - Fax:502-459-4662
Practice Address - Street 1:3071 BRECKENRIDGE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2101
Practice Address - Country:US
Practice Address - Phone:502-459-4150
Practice Address - Fax:502-459-4662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4122261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY62178Medicare UPIN
KY1129511Medicare ID - Type UnspecifiedPASSPORT
KY0629804Medicare ID - Type Unspecified
KY2437566000Medicare ID - Type UnspecifiedPASSPORT ADVANTAGE