Provider Demographics
NPI:1699159723
Name:IMPACT PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:IMPACT PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-209-4466
Mailing Address - Street 1:96 YELLOW CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930
Mailing Address - Country:US
Mailing Address - Phone:307-444-4466
Mailing Address - Fax:307-444-4468
Practice Address - Street 1:96 YELLOW CREEK ROAD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-444-4466
Practice Address - Fax:307-444-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1568261QP2000X
WYPT 1683261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy