Provider Demographics
NPI:1124547021
Name:IMPACT INJURY CENTER, LLC
Entity Type:Organization
Organization Name:IMPACT INJURY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-899-7290
Mailing Address - Street 1:19365 SW 65TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-482-5719
Mailing Address - Fax:503-482-5731
Practice Address - Street 1:460 N VILLA RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1800
Practice Address - Country:US
Practice Address - Phone:033-056-5855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty