Provider Demographics
NPI:1992159701
Name:EVOLVE CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:EVOLVE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-856-1242
Mailing Address - Street 1:211 KRUMMEL LN
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:PA
Mailing Address - Zip Code:18326-7051
Mailing Address - Country:US
Mailing Address - Phone:570-856-1242
Mailing Address - Fax:
Practice Address - Street 1:1101 ROUTE 390
Practice Address - Street 2:SUITE 3
Practice Address - City:MOUNTAINHOME
Practice Address - State:PA
Practice Address - Zip Code:18342
Practice Address - Country:US
Practice Address - Phone:570-856-1242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011126111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty