Provider Demographics
NPI:1538499959
Name:IMPACT PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:IMPACT PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KINAL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-623-0497
Mailing Address - Street 1:5314 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1611
Mailing Address - Country:US
Mailing Address - Phone:248-623-0497
Mailing Address - Fax:248-623-0546
Practice Address - Street 1:5314 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-1611
Practice Address - Country:US
Practice Address - Phone:248-623-0497
Practice Address - Fax:248-623-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P26760-002Medicare PIN