Provider Demographics
NPI:1649904079
Name:EVOLUTION PHYSICAL THERAPY
Entity type:Organization
Organization Name:EVOLUTION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-915-6100
Mailing Address - Street 1:47 HEISSER LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3314
Mailing Address - Country:US
Mailing Address - Phone:516-665-0882
Mailing Address - Fax:516-665-0884
Practice Address - Street 1:47 HEISSER LN
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3314
Practice Address - Country:US
Practice Address - Phone:516-665-0882
Practice Address - Fax:516-665-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy