MEDICARE: PROIMPACT PHYSICAL THERAPY & SPORTS PERFORMANCE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTH1388	AL

General Provider Information

NPI Number	:	1942580899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROIMPACT PHYSICAL THERAPY & SPORTS PERFORMANCE

Provider Business Mailing Address
First Line	:	5923 MONTICELLO DRIVE
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-1940
Country	:	US
Telephone Number	:	334-356-6453
Fax Number	:	334-239-8126

Provider Business Practice Location Address
First Line	:	5923 MONTICELLO DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-1940
Country	:	US
Telephone Number	:	334-356-6453
Fax Number	:	334-239-8126

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CHARLES MICHAEL ELLIS
Credential	:	PT, ATC
Telephone Number	:	334-356-6453

Provider Enumeration Date	:	08/24/2011
Last Update Date	:	08/24/2011

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