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General NPI Number Information
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NPI Number | 1790387694
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Entity Type | Organization
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Legal Business Name | IMPACTMEDICAL, LLC
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Dates
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Enumeration Date | 11/15/2020
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Last Update Date | 11/15/2020
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Provider Practice Location Address
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Address Line | 701 W GLENDALE AVE
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City | PHOENIX
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State | AZ
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Zip | 85021-8629
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Country | US
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Telephone | 602-762-1128
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Fax |
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Provider Business Mailing Address
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Address Line | 7000 N 16TH ST STE 102-201
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City | PHOENIX
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State | AZ
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Zip | 85020-5512
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Country | US
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Telephone | 602-762-1128
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MATTHEW COEN
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Credential | DC
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Telephone | 602-762-1128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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