Healthcare Provider Details

I. General information

NPI: 1215319413
Provider Name (Legal Business Name): IMPACT PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 W DEER VALLEY RD
PEORIA AZ
85382
US

IV. Provider business mailing address

7727 W DEER VALLEY RD
PEORIA AZ
85382-2116
US

V. Phone/Fax

Practice location:
  • Phone: 623-208-7575
  • Fax: 866-281-9664
Mailing address:
  • Phone: 623-208-7575
  • Fax: 866-281-9664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7917
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC HEFFERON
Title or Position: CEO/OWNER
Credential: DPT
Phone: 602-639-1066