=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821425752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT HEALTH SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2013
-----------------------------------------------------
Last Update Date | 10/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2615 STRAWBERRY RD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77502-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-532-9063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16325 WESTHEIMER RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77082-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-475-4559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | AIJAZ ALI KHOWAJA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-475-4559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------