MEDICARE: IMPACT ATHLETICS INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	133V00000X	Registered Dietitian
2	363LF0000X	Family Nurse Practitioner
3	225100000X	Physical Therapist
4	2251X0800X	Orthopedic Physical Therapist
5	2083S0010X	Sports Medicine (Preventive Medicine) Physician

General Provider Information

NPI Number	:	1568203610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT ATHLETICS INCORPORATED

Provider Business Mailing Address
First Line	:	9525 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9525 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1310
Country	:	US
Telephone Number	:	317-669-2375
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JACK HAM
Credential	:
Telephone Number	:	669-666-4936

Provider Enumeration Date	:	06/03/2024
Last Update Date	:	07/13/2024

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Directions to “IMPACT ATHLETICS INCORPORATED ” Practice Location

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