Organization
PROTAILORED PHYSICAL THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JONATHAN T EVANS PT, DPT (PHYSICAL THERAPIST/OWNER)
(260) 570-8239
Entity
Organization
Contact information
Practice address
12722 TONKEL RD STE 102, FORT WAYNE, IN 46845-8201
(260) 739-0300
(260) 818-2299
Mailing address
12722 TONKEL RD STE 102, FORT WAYNE, IN 46845-8201
(260) 739-0300
(260) 818-2299
Taxonomy
Speciality
Code
Description
License number
State
2251X0800X
Orthopedic Physical Therapist
Primary
05011654A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201289250A
—
IN
Enumeration date
03/14/2015
Last updated
06/01/2020
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