MEDICARE: IMPACT HEALTH & WELLNESS 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	172M00000X	Mechanotherapist	CAMTC 20733	CA

General Provider Information

NPI Number	:	1609159193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT HEALTH & WELLNESS LLC

Provider Business Mailing Address
First Line	:	2025 NEWPORT BLVD
Second Line	:	SUITE 110
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2162
Country	:	US
Telephone Number	:	949-954-6225
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 NEWPORT BLVD
Second Line	:	SUITE 110
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2162
Country	:	US
Telephone Number	:	949-954-6225
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	MANUEL ARAGON
Credential	:	CMT
Telephone Number	:	949-954-6225

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	09/21/2011

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Directions to “IMPACT HEALTH & WELLNESS LLC ” Practice Location

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