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General NPI Number Information
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NPI Number | 1568203610
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Entity Type | Organization
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Legal Business Name | IMPACT ATHLETICS INCORPORATED
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Dates
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Enumeration Date | 06/03/2024
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Last Update Date | 07/13/2024
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Provider Practice Location Address
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Address Line | 9525 N MERIDIAN ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-1310
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Country | US
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Telephone | 317-669-2375
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Fax |
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Provider Business Mailing Address
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Address Line | 9525 N MERIDIAN ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-1310
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JACK HAM
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Credential |
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Telephone | 669-666-4936
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2083S0010X
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Taxonomy Name | Sports Medicine (Preventive Medicine) Physician
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License Number |
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License Number State |
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