Healthcare Provider Details

I. General information

NPI: 1518224740
Provider Name (Legal Business Name): FIRST IMPACT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 INDIANA AVE SUITE 145
RIVERSIDE CA
92506-4290
US

IV. Provider business mailing address

PO BOX 28807
SANTA ANA CA
92799-8807
US

V. Phone/Fax

Practice location:
  • Phone: 888-951-9511
  • Fax:
Mailing address:
  • Phone: 888-951-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY9462
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number21702
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number13813
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA79570
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number4540
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA72007
License Number StateCA

VIII. Authorized Official

Name: DR. NICK MASHOUR
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 888-951-9511