=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497966816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN R EVANS CMT, ABW, RYT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 08/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 643A EAST BLITHEDALE
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-717-7764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 307
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94942-0307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-717-7764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | NOT APPLICABLE
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------