Healthcare Provider Details

I. General information

NPI: 1275087033
Provider Name (Legal Business Name): IMPACT NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13636 HIGHLAND RD
BATON ROUGE LA
70810-5013
US

IV. Provider business mailing address

11408 LAKE SHERWOOD AVE N SUITE A
BATON ROUGE LA
70816-0406
US

V. Phone/Fax

Practice location:
  • Phone: 225-505-7104
  • Fax:
Mailing address:
  • Phone: 225-214-0077
  • Fax: 225-214-3423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMAD ZOHAIR PIRZADAH
Title or Position: OWNER
Credential: MD
Phone: 225-505-7104