Provider Demographics
NPI:1548039621
Name:EVOLVED CHIROPRACTIC
Entity type:Organization
Organization Name:EVOLVED CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MUDLAFF
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:262-305-9064
Mailing Address - Street 1:331 E PUETZ RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-3254
Mailing Address - Country:US
Mailing Address - Phone:414-667-2838
Mailing Address - Fax:
Practice Address - Street 1:331 E PUETZ RD STE 101
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-3254
Practice Address - Country:US
Practice Address - Phone:414-667-2838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty