=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154712156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT MEDICAL STAFFING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2015
-----------------------------------------------------
Last Update Date | 02/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 193 HARP DR
-----------------------------------------------------
City | RIPON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95366-9334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-603-0716
-----------------------------------------------------
Fax | 209-599-7478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 193 HARP DR
-----------------------------------------------------
City | RIPON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95366-9334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-603-0716
-----------------------------------------------------
Fax | 209-599-7478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MELANIE AQUINO DUNNIWAY
-----------------------------------------------------
Credential | OT
-----------------------------------------------------
Telephone | 209-603-0716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 9409
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------