Healthcare Provider Details

I. General information

NPI: 1619701935
Provider Name (Legal Business Name): EVOLVE SPINE AND SPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8999 SAINT CHARLES ROCK RD
SAINT LOUIS MO
63114-4260
US

IV. Provider business mailing address

8999 SAINT CHARLES ROCK RD
SAINT LOUIS MO
63114-4260
US

V. Phone/Fax

Practice location:
  • Phone: 314-428-3343
  • Fax: 314-428-3338
Mailing address:
  • Phone: 314-428-3343
  • Fax: 314-428-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JORDAN REED
Title or Position: OWNER/CHIROPRACTOR
Credential: DC
Phone: 314-681-5089