1942458617 NPI number — EVOLVE PHYSICAL THERAPY, LLC

Table of content: HEATHER A. ANGELILLO RD,CDN (NPI 1205029956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942458617 NPI number — EVOLVE PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLVE PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942458617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
137 MAIN ST
Provider Second Line Business Mailing Address:
G-001
Provider Business Mailing Address City Name:
EDWARDS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81632-8118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-470-2611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
137 MAIN ST
Provider Second Line Business Practice Location Address:
G-001
Provider Business Practice Location Address City Name:
EDWARDS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81632-8118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-470-2611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERGERON
Authorized Official First Name:
KERI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHYSICAL THERAPIST, REGISTERED AGEN
Authorized Official Telephone Number:
970-470-2611

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  8661 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 97734543 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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