NPIMap

Organization Active NPI

Impact Physical Therapy, LLC

  • Physical Therapist
  • Lebanon, TN
National Provider Identifier
1174709430
Registry record updated May 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
IMPACT PHYSICAL THERAPY, LLC
Practice address
1430 W Baddour Pkwy
Suite C
Lebanon, TN 37087-2514
Phone
(615) 453-1422
Fax
(615) 453-1429
NPI assigned
Jan 17, 2008
Last updated
May 12, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John Boucher, P.T.NPI 1457371718
Title
Owner
Phone
(615) 453-1422

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X NU Primary

Addresses

Primary practice location

1430 W Baddour Pkwy
Suite C
Lebanon, TN 37087-2514

Mailing address

1430 W Baddour Pkwy Ste C
Lebanon, TN 37087-2656
Phone (615) 453-1422

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080417000691 TN Part B Supplier - Clinic/Group Practice 8123106077 Receives reassigned benefits from 5 practitioners
2 other NPIs on this enrollment
Practice locations: Lebanon, TN; Watertown, TN

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Impact Physical Therapy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1200528000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1683849600000",
    "number": "1174709430",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1430 W BADDOUR PKWY STE C",
            "city": "LEBANON",
            "state": "TN",
            "postal_code": "370872656",
            "telephone_number": "615-453-1422",
            "fax_number": "615-453-1429"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1430 W BADDOUR PKWY",
            "address_2": "SUITE C",
            "city": "LEBANON",
            "state": "TN",
            "postal_code": "370872514",
            "telephone_number": "615-453-1422",
            "fax_number": "615-453-1429"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-17",
        "last_updated": "2023-05-12",
        "certification_date": "2023-05-12",
        "status": "A",
        "authorized_official_last_name": "BOUCHER",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "615-453-1422",
        "authorized_official_credential": "P.T."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lebanon, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 12, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.