1073100764 NPI number — EVOLUTION THERAPY IN MOTION, PLLC

Table of content: (NPI 1073100764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073100764 NPI number — EVOLUTION THERAPY IN MOTION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUTION THERAPY IN MOTION, PLLC
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:
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NPI Number Information

NPI Number:
1073100764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 BARRY ROSE RD APT 1205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77581-4607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-915-9632
Provider Business Mailing Address Fax Number:
281-519-7845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 BARRY ROSE RD APT 1205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77581-4607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-915-9632
Provider Business Practice Location Address Fax Number:
281-519-7845
Provider Enumeration Date:
12/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
COTTON
Authorized Official First Name:
JACOBY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-915-9632

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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