MEDICARE: IMPACT Q TESTING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1114383619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT Q TESTING LLC

Provider Business Mailing Address
First Line	:	2234 W ATLANTIC AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-4674
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2234 W ATLANTIC AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-4674
Country	:	US
Telephone Number	:	516-697-4791
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANIEL KANDLER
Credential	:
Telephone Number	:	516-697-4791

Provider Enumeration Date	:	01/13/2016
Last Update Date	:	01/13/2016

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