Provider Demographics
NPI:1306688320
Name:IMPACT PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:IMPACT PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CSCS
Authorized Official - Phone:601-502-3765
Mailing Address - Street 1:1135 ANGELICA ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5594
Mailing Address - Country:US
Mailing Address - Phone:601-502-3765
Mailing Address - Fax:
Practice Address - Street 1:843 FAIRVIEW AVE STE B5
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4975
Practice Address - Country:US
Practice Address - Phone:601-502-3765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy