Provider Demographics
NPI:1134772247
Name:CMP IMPACT THERAPEUTIC SERVICES
Entity type:Organization
Organization Name:CMP IMPACT THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:478-225-6404
Mailing Address - Street 1:1906 ELBERTA RD STE C
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-1391
Mailing Address - Country:US
Mailing Address - Phone:478-225-6404
Mailing Address - Fax:
Practice Address - Street 1:1906 ELBERTA RD STE C
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1391
Practice Address - Country:US
Practice Address - Phone:478-225-6404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty