Provider Demographics
NPI:1831187863
Name:IMPAC REHABILITATION, INC
Entity type:Organization
Organization Name:IMPAC REHABILITATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MCVAY
Authorized Official - Suffix:
Authorized Official - Credentials:SPEECH PATHOLOGIST
Authorized Official - Phone:507-779-0400
Mailing Address - Street 1:4937 HEARST STREET
Mailing Address - Street 2:SUITE 2-F
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001
Mailing Address - Country:US
Mailing Address - Phone:504-779-0400
Mailing Address - Fax:
Practice Address - Street 1:4937 HEARST STREET
Practice Address - Street 2:SUITE 2-F
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001
Practice Address - Country:US
Practice Address - Phone:504-779-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1438413Medicaid
LA1438413Medicaid