Provider Demographics
NPI:1457417131
Name:IMPACT PHYSICAL MEDICINE AND AQUATIC CENTER
Entity Type:Organization
Organization Name:IMPACT PHYSICAL MEDICINE AND AQUATIC CENTER
Other - Org Name:IMPACT PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BABEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-999-1030
Mailing Address - Street 1:1600 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3898
Mailing Address - Country:US
Mailing Address - Phone:651-646-7246
Mailing Address - Fax:651-641-0726
Practice Address - Street 1:1600 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 10
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3898
Practice Address - Country:US
Practice Address - Phone:651-646-7246
Practice Address - Fax:651-641-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy