=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497861926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT REHABILITATION AND SPORTS MEDICINE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 04/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 CARRINGTON LN STE C
-----------------------------------------------------
City | CALERA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35040-5439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-621-3077
-----------------------------------------------------
Fax | 205-621-3788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1694
-----------------------------------------------------
City | CALERA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35040-1694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-621-3077
-----------------------------------------------------
Fax | 205-621-3788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL CHADWICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-621-3077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------