=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396879706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5261 E KINGS CANYON RD SUITE 107
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93727-4028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-452-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5261 E KINGS CANYON RD SUITE 107
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93727-4028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-452-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROPRIETOR
-----------------------------------------------------
Name | DR. IFEATU EKELEM
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 559-452-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146D00000X
-----------------------------------------------------
Taxonomy Name | Personal Emergency Response Attendant
-----------------------------------------------------
License Number | A43177
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------