Provider Demographics
NPI:1518224740
Name:FIRST IMPACT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:FIRST IMPACT MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MASHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-951-9511
Mailing Address - Street 1:PO BOX 28807
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92799-8807
Mailing Address - Country:US
Mailing Address - Phone:888-951-9511
Mailing Address - Fax:
Practice Address - Street 1:6700 INDIANA AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4290
Practice Address - Country:US
Practice Address - Phone:888-951-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9462103T00000X
CA21702111N00000X
CA13813171100000X
CAA72007207R00000X
CAA79570208100000X
CA4540213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty