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General NPI Number Information
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NPI Number | 1417214230
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Entity Type | Organization
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Legal Business Name | IMPACT HEALTH
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Dates
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Enumeration Date | 04/18/2012
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Last Update Date | 04/18/2012
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Provider Practice Location Address
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Address Line | 1401 SE WALTON BLVD 113
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City | BENTONVILLE
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State | AR
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Zip | 72712-3759
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Country | US
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Telephone | 479-254-3999
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Fax | 479-254-3998
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Provider Business Mailing Address
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Address Line | 1401 SE WALTON BLVD 113
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City | BENTONVILLE
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State | AR
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Zip | 72712-3759
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Country | US
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Telephone | 479-254-3999
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Fax | 479-254-3998
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. HARVEY J ROEDER III
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Credential | D.C.
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Telephone | 479-254-3999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 154720
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License Number State | AR
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