Provider Demographics
NPI:1942458617
Name:EVOLVE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:EVOLVE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, REGISTERED AGEN
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:970-470-2611
Mailing Address - Street 1:137 MAIN ST
Mailing Address - Street 2:G-001
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-8118
Mailing Address - Country:US
Mailing Address - Phone:970-470-2611
Mailing Address - Fax:
Practice Address - Street 1:137 MAIN ST
Practice Address - Street 2:G-001
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-8118
Practice Address - Country:US
Practice Address - Phone:970-470-2611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8661261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97734543Medicaid
CO801717Medicare PIN
CO97734543Medicaid