Basic Information
| Provider Information | |||||||||
| NPI: | 1093715773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANS REHABILITATION SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 TOWN PARK BLVD. | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068681707 | ||||||||
| FaxNumber: | 7068681351 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 TOWN PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068681707 | ||||||||
| FaxNumber: | 7068681351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | LOTT | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7068681707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.