Healthcare Provider Details

I. General information

NPI: 1174709430
Provider Name (Legal Business Name): IMPACT PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 W BADDOUR PKWY SUITE C
LEBANON TN
37087-2514
US

IV. Provider business mailing address

1430 W BADDOUR PKWY STE C
LEBANON TN
37087-2656
US

V. Phone/Fax

Practice location:
  • Phone: 615-453-1422
  • Fax: 615-453-1429
Mailing address:
  • Phone: 615-453-1422
  • Fax: 615-453-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOHN BOUCHER
Title or Position: OWNER
Credential: P.T.
Phone: 615-453-1422