Provider Demographics
NPI:1346706025
Name:IMPACT PHYSICAL THERAPY AND PERFORMANCE, P.C.
Entity Type:Organization
Organization Name:IMPACT PHYSICAL THERAPY AND PERFORMANCE, P.C.
Other - Org Name:KO GOLF PERFORMANCE AND PHYSICAL THERAPY, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER - PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:949-378-9985
Mailing Address - Street 1:34 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 SERENITY LN
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5905
Practice Address - Country:US
Practice Address - Phone:949-378-9985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-18
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty