Basic Information
| Provider Information | |||||||||
| NPI: | 1356511455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPACT PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5002 CROSSINGS CIR | ||||||||
| Address2: | |||||||||
| City: | MOUNT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371228471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5002 CROSSINGS CIR | ||||||||
| Address2: | |||||||||
| City: | MOUNT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371228471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOUCHER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6155535500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.