Provider Demographics
NPI:1477955086
Name:IMPACT GENETICS CORP
Entity Type:Organization
Organization Name:IMPACT GENETICS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:LN
Authorized Official - Last Name:JEWETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:647-478-4902
Mailing Address - Street 1:10880 WILSHIRE BLVD STE 1101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4112
Mailing Address - Country:US
Mailing Address - Phone:647-478-4902
Mailing Address - Fax:905-697-9786
Practice Address - Street 1:10880 WILSHIRE BLVD STE 1101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4112
Practice Address - Country:US
Practice Address - Phone:647-478-4902
Practice Address - Fax:905-697-9786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ99D990947291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory