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General NPI Number Information
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NPI Number | 1598079758
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Entity Type | Organization
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Legal Business Name | EVOLVE CENTER FOR FUNCTIONAL MEDICINE, LLC
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Dates
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Enumeration Date | 07/29/2010
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Last Update Date | 07/29/2010
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Provider Practice Location Address
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Address Line | 506 W BASELINE RD
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City | LAFAYETTE
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State | CO
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Zip | 80026-1723
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Country | US
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Telephone | 303-666-7685
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Fax |
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Provider Business Mailing Address
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Address Line | 506 W BASELINE RD
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City | LAFAYETTE
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State | CO
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Zip | 80026-1723
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Country | US
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Telephone | 303-666-7685
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STEPHANIE MARIE HATH
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Credential | D.C.
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Telephone | 303-666-7685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number | CHR6544
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License Number State | CO
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