Healthcare Provider Details

I. General information

NPI: 1992263164
Provider Name (Legal Business Name): IMPACT MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 ASHLEY OAKS CIR
WESLEY CHAPEL FL
33544-6400
US

IV. Provider business mailing address

PO BOX 7982
SEMINOLE FL
33775-7982
US

V. Phone/Fax

Practice location:
  • Phone: 813-953-1002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA N BOTBYL
Title or Position: ADMINISTRATOR
Credential:
Phone: 727-272-4919