Provider Demographics
NPI:1215437249
Name:EVOLVE RESTORATIVE CENTER
Entity type:Organization
Organization Name:EVOLVE RESTORATIVE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNTLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-495-9632
Mailing Address - Street 1:220 CONCOURSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8210
Mailing Address - Country:US
Mailing Address - Phone:844-527-7369
Mailing Address - Fax:
Practice Address - Street 1:220 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8210
Practice Address - Country:US
Practice Address - Phone:844-527-7369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty