Provider Demographics
NPI:1730596511
Name:EVOLUTION HEALTHCARE, REHAB., & FITNESS
Entity type:Organization
Organization Name:EVOLUTION HEALTHCARE, REHAB., & FITNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-975-6566
Mailing Address - Street 1:4279 SE HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5816
Mailing Address - Country:US
Mailing Address - Phone:503-975-6566
Mailing Address - Fax:
Practice Address - Street 1:2332 NW IRVING ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3225
Practice Address - Country:US
Practice Address - Phone:503-222-1865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3851261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care