Provider Demographics
NPI:1306927496
Name:IMPACT SPORTS MEDICINE PC
Entity type:Organization
Organization Name:IMPACT SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:CHRISTIANSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT ATC MTC
Authorized Official - Phone:303-446-2200
Mailing Address - Street 1:PO BOX 270217
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-5003
Mailing Address - Country:US
Mailing Address - Phone:303-446-2200
Mailing Address - Fax:303-446-2201
Practice Address - Street 1:3303 W 144TH AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-9464
Practice Address - Country:US
Practice Address - Phone:303-446-2200
Practice Address - Fax:303-446-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC806499Medicare PIN