Provider Demographics
NPI:1578923066
Name:IMPACT REHABILITATION LLC
Entity Type:Organization
Organization Name:IMPACT REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-1706
Mailing Address - Street 1:2028 W OAKTON ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2028 W OAKTON ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1958
Practice Address - Country:US
Practice Address - Phone:708-478-1706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-004993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL91024Medicare PIN