Healthcare Provider Details

I. General information

NPI: 1245895739
Provider Name (Legal Business Name): IMPACT PHYSICAL THERAPY - 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20801 N SCOTTSDALE RD STE 105
SCOTTSDALE AZ
85255-6487
US

IV. Provider business mailing address

20801 N SCOTTSDALE RD STE 105
SCOTTSDALE AZ
85255-6487
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC HEFFERON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 623-208-7575