Provider Demographics
NPI:1801817739
Name:IMPACT REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:IMPACT REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SUTCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, ATC
Authorized Official - Phone:714-288-9125
Mailing Address - Street 1:PO BOX 5986
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5986
Mailing Address - Country:US
Mailing Address - Phone:714-288-9125
Mailing Address - Fax:714-288-9129
Practice Address - Street 1:255 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7772
Practice Address - Country:US
Practice Address - Phone:714-288-9125
Practice Address - Fax:714-288-9129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-03-30
Deactivation Date:2018-07-13
Deactivation Code:
Reactivation Date:2018-08-08
Provider Licenses
StateLicense IDTaxonomies
CAPT26858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001400Medicaid
CAGPT001400Medicaid