Basic Information
| Provider Information | |||||||||
| NPI: | 1811946023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVOLVE PHYSICAL THERAPY AND SPORTS CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1103 CYPRESS CREEK RD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786133924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129180044 | ||||||||
| FaxNumber: | 5129180045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 CYPRESS CREEK RD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786133924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129180044 | ||||||||
| FaxNumber: | 5129180045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | GAYLE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5129180044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, MA, OCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.