Provider Demographics
NPI:1356696579
Name:IMPACT PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:IMPACT PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:NAMSU
Authorized Official - Last Name:YI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-660-2485
Mailing Address - Street 1:60 DUTCH HILL RD
Mailing Address - Street 2:2
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-1723
Mailing Address - Country:US
Mailing Address - Phone:201-660-2485
Mailing Address - Fax:845-359-2095
Practice Address - Street 1:60 DUTCH HILL RD
Practice Address - Street 2:2
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1723
Practice Address - Country:US
Practice Address - Phone:201-660-2485
Practice Address - Fax:845-359-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-14
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017357261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy