Provider Demographics
NPI:1689420531
Name:EVOLUTION MOM LLC
Entity type:Organization
Organization Name:EVOLUTION MOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:908-797-1546
Mailing Address - Street 1:15 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NJ
Mailing Address - Zip Code:08833-4100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1465 ROUTE 31 S
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:NJ
Practice Address - Zip Code:08801-3129
Practice Address - Country:US
Practice Address - Phone:908-797-1546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy