Healthcare Provider Details

I. General information

NPI: 1457008971
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, WASHINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 NE 129TH ST
VANCOUVER WA
98686-3324
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 360-356-1890
  • Fax:
Mailing address:
  • Phone: 678-967-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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