Provider Demographics
NPI:1407434632
Name:IMPACT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:IMPACT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:504-491-5249
Mailing Address - Street 1:13702 COURSEY BLVD STE 10B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1370
Mailing Address - Country:US
Mailing Address - Phone:504-491-5249
Mailing Address - Fax:
Practice Address - Street 1:13702 COURSEY BLVD STE 10B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1370
Practice Address - Country:US
Practice Address - Phone:504-491-5249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty