=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821649088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT PHYSICAL THERAPY & PERFORMANCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2019
-----------------------------------------------------
Last Update Date | 09/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1155 CLARITY DR
-----------------------------------------------------
City | VERONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53593-9318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-293-4508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W4850 PEMBRIDGE TRL
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53566-8745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-293-4508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDING OWNER
-----------------------------------------------------
Name | DR. MATTHEW KOESTER
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 608-293-4508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------