Provider Demographics
NPI:1487885554
Name:IMPACT PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:IMPACT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:814-881-9193
Mailing Address - Street 1:5415 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2841
Mailing Address - Country:US
Mailing Address - Phone:814-838-2133
Mailing Address - Fax:814-838-2355
Practice Address - Street 1:5415 W LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-2841
Practice Address - Country:US
Practice Address - Phone:814-838-2133
Practice Address - Fax:814-838-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006544L174400000X
PAPT008392L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADR7707OtherRAILROAD MEDICARE
PA1023738100001Medicaid
PA1023738100001Medicaid