Provider Demographics
NPI:1578394995
Name:EVOLUTION MEDICAL & AESTHETICS
Entity type:Organization
Organization Name:EVOLUTION MEDICAL & AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-817-3542
Mailing Address - Street 1:239 CLIFFORD PRICE LOOP
Mailing Address - Street 2:
Mailing Address - City:MOORESBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37811
Mailing Address - Country:US
Mailing Address - Phone:423-754-9648
Mailing Address - Fax:
Practice Address - Street 1:3815 TN-66
Practice Address - Street 2:SUITE 1
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857
Practice Address - Country:US
Practice Address - Phone:423-817-3542
Practice Address - Fax:423-717-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center