Provider Demographics
NPI:1821649088
Name:IMPACT PHYSICAL THERAPY & PERFORMANCE LLC
Entity Type:Organization
Organization Name:IMPACT PHYSICAL THERAPY & PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KOESTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:608-293-4508
Mailing Address - Street 1:W4850 PEMBRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-8745
Mailing Address - Country:US
Mailing Address - Phone:608-293-4508
Mailing Address - Fax:
Practice Address - Street 1:1155 CLARITY DR
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-9318
Practice Address - Country:US
Practice Address - Phone:608-293-4508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245889229Medicaid