Healthcare Provider Details

I. General information

NPI: 1043626724
Provider Name (Legal Business Name): EVOLVE OCCUPATIONAL & PHYSICAL THERAPY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11490 BRADDOCK DR
CULVER CITY CA
90230-5151
US

IV. Provider business mailing address

11490 BRADDOCK DR
CULVER CITY CA
90230-5151
US

V. Phone/Fax

Practice location:
  • Phone: 856-220-1460
  • Fax: 855-330-1292
Mailing address:
  • Phone: 856-220-1460
  • Fax: 855-330-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LORI KENUK
Title or Position: CEO, PRESIDENT
Credential: PT, DPT
Phone: 856-220-1460