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General NPI Number Information
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NPI Number | 1275072936
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Entity Type | Organization
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Legal Business Name | EVOLUTION WELLNESS
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 02/14/2017
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Provider Practice Location Address
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Address Line | 7700 N CAPITAL OF TEXAS HWY 726
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City | AUSTIN
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State | TX
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Zip | 78731-1183
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Country | US
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Telephone | 773-368-8682
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Fax |
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Provider Business Mailing Address
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Address Line | 7700 N CAPITAL OF TEXAS HWY 726
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City | AUSTIN
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State | TX
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Zip | 78731-1183
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Country | US
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Telephone | 773-368-8682
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JENNIFER A MITOL
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Credential | PT
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Telephone | 773-368-8682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 1235920
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License Number State | TX
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