Basic Information
| Provider Information | |||||||||
| NPI: | 1245993765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPACT MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 S DILLARD ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632293537 | ||||||||
| FaxNumber: | 4076343207 | ||||||||
| Practice Location | |||||||||
| Address1: | 6735 CONROY RD STE 331 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328353568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076148898 | ||||||||
| FaxNumber: | 4076343207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2021 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | HEALY | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7632293537 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.