MEDICARE: IMPACT TECHNOLOGIES GROUP 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	335E00000X	Prosthetic/Orthotic Supplier	2009-00747	FL
2	332B00000X	Durable Medical Equipment & Medical Supplies	2009-00747	FL

General Provider Information

NPI Number	:	1639302045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT TECHNOLOGIES GROUP LLC

Provider Business Mailing Address
First Line	:	5401 N HAVERHILL RD
Second Line	:	SUITE 125
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-7005
Country	:	US
Telephone Number	:	561-317-7546
Fax Number	:	561-296-6643

Provider Business Practice Location Address
First Line	:	5401 N HAVERHILL RD
Second Line	:	SUITE 125
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-7005
Country	:	US
Telephone Number	:	561-317-7546
Fax Number	:	561-296-6643

Authorized Official
Title or Position	:	CEO
Name	:	MS. ANGELINA CEJA
Credential	:
Telephone Number	:	561-317-7546

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	09/02/2009

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