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General NPI Number Information
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NPI Number | 1801554852
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Entity Type | Organization
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Legal Business Name | EVOLUTION CHIROPRACTIC AND WELLNESS
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Dates
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Enumeration Date | 12/07/2021
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Last Update Date | 12/07/2021
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Provider Practice Location Address
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Address Line | 947 E WINDING CREEK DR STE 200
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City | EAGLE
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State | ID
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Zip | 83616-7231
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Country | US
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Telephone | 503-756-5317
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Fax |
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Provider Business Mailing Address
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Address Line | 947 E WINDING CREEK DR STE 200
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City | EAGLE
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State | ID
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Zip | 83616-7231
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Country | US
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Telephone | 503-756-5317
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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. JEREMY PAYNE
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Credential | DC
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Telephone | 208-917-2928
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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