Healthcare Provider Details

I. General information

NPI: 1013890128
Provider Name (Legal Business Name): IMPACT THERAPY & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 HOTEL AVE
EDGEWATER FL
32132-2362
US

IV. Provider business mailing address

131 HOTEL AVE
EDGEWATER FL
32132-2362
US

V. Phone/Fax

Practice location:
  • Phone: 954-560-0782
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA HILL
Title or Position: CEO
Credential: OTR/L
Phone: 954-560-0782