Healthcare Provider Details

I. General information

NPI: 1861858904
Provider Name (Legal Business Name): IMPACT CARE ACCESS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9390 HESPERIA RD SUITE # 7
HESPERIA CA
92345-3602
US

IV. Provider business mailing address

9390 HESPERIA RD SUITE # 7
HESPERIA CA
92345-3602
US

V. Phone/Fax

Practice location:
  • Phone: 760-998-2125
  • Fax: 760-948-0723
Mailing address:
  • Phone: 760-998-2125
  • Fax: 760-948-0723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberG69428
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberG69428
License Number StateCA

VIII. Authorized Official

Name: DR. PHILIP DIMITRIOS KOUROS
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 760-948-4219