Provider Demographics
NPI:1942580899
Name:PROIMPACT PHYSICAL THERAPY & SPORTS PERFORMANCE
Entity Type:Organization
Organization Name:PROIMPACT PHYSICAL THERAPY & SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:334-356-6453
Mailing Address - Street 1:5923 MONTICELLO DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-1940
Mailing Address - Country:US
Mailing Address - Phone:334-356-6453
Mailing Address - Fax:334-239-8126
Practice Address - Street 1:5923 MONTICELLO DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-1940
Practice Address - Country:US
Practice Address - Phone:334-356-6453
Practice Address - Fax:334-239-8126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty