Healthcare Provider Details

I. General information

NPI: 1689290603
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 RUE DE JARDIN STE 100
LAKE CHARLES LA
70605-4050
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 260-407-8009
  • Fax: 260-407-8009
Mailing address:
  • Phone: 678-967-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CEO
Credential:
Phone: 678-967-5599