Healthcare Provider Details

I. General information

NPI: 1710349220
Provider Name (Legal Business Name): EVOLV STRONG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CANDELARIA RD NE
ALBUQUERQUE NM
87107
US

IV. Provider business mailing address

3201 CANDELARIA RD NE
ALBUQUERQUE NM
87107-1906
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-3408
  • Fax:
Mailing address:
  • Phone: 505-872-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CURT JASON CHAVEZ
Title or Position: OWNER
Credential: AT,MBA
Phone: 505-872-3408