Provider Demographics
NPI:1811946023
Name:EVOLVE PHYSICAL THERAPY AND SPORTS CENTER INC
Entity type:Organization
Organization Name:EVOLVE PHYSICAL THERAPY AND SPORTS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MA, OCS
Authorized Official - Phone:512-918-0044
Mailing Address - Street 1:1103 CYPRESS CREEK RD
Mailing Address - Street 2:STE 103
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3924
Mailing Address - Country:US
Mailing Address - Phone:512-918-0044
Mailing Address - Fax:512-918-0045
Practice Address - Street 1:1103 CYPRESS CREEK RD
Practice Address - Street 2:STE 103
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3924
Practice Address - Country:US
Practice Address - Phone:512-918-0044
Practice Address - Fax:512-918-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W668Medicare ID - Type UnspecifiedGROUP LEGACY NUMBER