Provider Demographics
NPI:1871066233
Name:IMPACT PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:IMPACT PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:715-529-3487
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:WI
Mailing Address - Zip Code:54406-0324
Mailing Address - Country:US
Mailing Address - Phone:715-529-3487
Mailing Address - Fax:715-251-6236
Practice Address - Street 1:485 CLINTON CT
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:WI
Practice Address - Zip Code:54406-9203
Practice Address - Country:US
Practice Address - Phone:715-824-4460
Practice Address - Fax:715-824-3278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty