Provider Demographics
NPI:1689021586
Name:IMPACT PHYSICAL MEDICINE
Entity type:Organization
Organization Name:IMPACT PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:612-250-2995
Mailing Address - Street 1:1600 UNIVERSITY AVE W STE 10
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3898
Mailing Address - Country:US
Mailing Address - Phone:651-646-7246
Mailing Address - Fax:651-641-0726
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 10
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3898
Practice Address - Country:US
Practice Address - Phone:651-646-7246
Practice Address - Fax:651-641-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105096261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center