Healthcare Provider Details

I. General information

NPI: 1629646336
Provider Name (Legal Business Name): BRADFORD EVOLVE TREATMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PROSPERITY DR
KNOXVILLE TN
37923-4711
US

IV. Provider business mailing address

2101 MAGNOLIA AVE S STE 518
BIRMINGHAM AL
35205-2853
US

V. Phone/Fax

Practice location:
  • Phone: 865-444-1658
  • Fax:
Mailing address:
  • Phone: 205-721-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK EDWARDS
Title or Position: CFO
Credential:
Phone: 205-244-8112