Healthcare Provider Details

I. General information

NPI: 1790387694
Provider Name (Legal Business Name): IMPACTMEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W GLENDALE AVE
PHOENIX AZ
85021-8629
US

IV. Provider business mailing address

7000 N 16TH ST STE 102-201
PHOENIX AZ
85020-5512
US

V. Phone/Fax

Practice location:
  • Phone: 602-762-1128
  • Fax:
Mailing address:
  • Phone: 602-762-1128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW COEN
Title or Position: DIRECTOR
Credential: DC
Phone: 602-762-1128