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General NPI Number Information
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NPI Number | 1770128746
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Entity Type | Individual
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Provider Name | JONALD BOYLES EVANGELISTA DPT
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Gender | Male
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Dates
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Enumeration Date | 11/13/2019
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 3157 FAIRLANE DR
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City | ALLEN PARK
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State | MI
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Zip | 48101-2866
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Country | US
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Telephone | 313-827-0099
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Fax | 313-749-0480
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Provider Business Mailing Address
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Address Line | 790 REMINGTON BLVD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-4909
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Country | US
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Telephone | 866-370-8206
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 032653
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4240
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License Number State | NV
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