Provider Demographics
NPI:1609501006
Name:IMPACT MEDICAL ASSOCIATES CALIFORNIA
Entity Type:Organization
Organization Name:IMPACT MEDICAL ASSOCIATES CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-905-9503
Mailing Address - Street 1:2889 W ASHTON BLVD STE 175
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6439
Mailing Address - Country:US
Mailing Address - Phone:584-878-7788
Mailing Address - Fax:858-487-2738
Practice Address - Street 1:11838 BERNARDO PLAZA CT STE 260A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2413
Practice Address - Country:US
Practice Address - Phone:858-487-8778
Practice Address - Fax:858-487-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty