Provider Demographics
NPI:1639302045
Name:IMPACT TECHNOLOGIES GROUP LLC
Entity Type:Organization
Organization Name:IMPACT TECHNOLOGIES GROUP LLC
Other - Org Name:ITGMEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CEJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-317-7546
Mailing Address - Street 1:5401 N HAVERHILL RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-7005
Mailing Address - Country:US
Mailing Address - Phone:561-317-7546
Mailing Address - Fax:561-296-6643
Practice Address - Street 1:5401 N HAVERHILL RD
Practice Address - Street 2:SUITE 125
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-7005
Practice Address - Country:US
Practice Address - Phone:561-317-7546
Practice Address - Fax:561-296-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2009-00747332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier