| Evolve 865 | |
|
460 Medical Park Dr Ste 102 Lenoir City TN 37772-6469 | |
| (865) 384-4865 | |
| Not Available |
| Full Name | Evolve 865 |
|---|---|
| Speciality | Clinic/Center |
| Location | 460 Medical Park Dr Ste 102, Lenoir City, Tennessee |
| Authorized Official Name and Position | Jill Dyvon Larson (OWNER/NP) |
| Authorized Official Contact | 8653844865 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Evolve 865 244 Warren Cove Ln Ste 102 Lenoir City TN 37772-3986 Ph: (865) 384-4865 | Evolve 865 460 Medical Park Dr Ste 102 Lenoir City TN 37772-6469 Ph: (865) 384-4865 |
| NPI Number | 1760189443 |
|---|---|
| Provider Enumeration Date | 02/13/2023 |
| Last Update Date | 02/13/2023 |
| Medicare PECOS PAC ID | 5294175162 |
|---|---|
| Medicare Enrollment ID | O20240426000111 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760189443 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| Provider Name | Jill D Larson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477678696 PECOS PAC ID: 4183786270 Enrollment ID: I20081226000045 |
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