Healthcare Provider Details

I. General information

NPI: 1346916632
Provider Name (Legal Business Name): EVOLUTIONS ON FIFTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 5TH ST N
COLUMBUS MS
39701-4522
US

IV. Provider business mailing address

122 5TH ST N
COLUMBUS MS
39701-4522
US

V. Phone/Fax

Practice location:
  • Phone: 662-630-5160
  • Fax:
Mailing address:
  • Phone: 662-630-5160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF BOLLING
Title or Position: DIRECTOR
Credential:
Phone: 662-497-0457