Provider Demographics
NPI:1851497440
Name:IMPACT PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:IMPACT PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOSOVA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:415-883-8323
Mailing Address - Street 1:3150 CALIFORNIA ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2464
Mailing Address - Country:US
Mailing Address - Phone:415-775-2319
Mailing Address - Fax:415-775-0852
Practice Address - Street 1:3150 CALIFORNIA ST
Practice Address - Street 2:SUITE #3
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2464
Practice Address - Country:US
Practice Address - Phone:415-775-2319
Practice Address - Fax:415-775-0852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PT218960261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18626ZMedicare ID - Type UnspecifiedPHYSICAL THERAPY GROUP