Provider Demographics
NPI:1861858904
Name:IMPACT CARE ACCESS NETWORK INC
Entity Type:Organization
Organization Name:IMPACT CARE ACCESS NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:DIMITRIOS
Authorized Official - Last Name:KOUROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-948-4219
Mailing Address - Street 1:9390 HESPERIA RD
Mailing Address - Street 2:SUITE # 7
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-3602
Mailing Address - Country:US
Mailing Address - Phone:760-998-2125
Mailing Address - Fax:760-948-0723
Practice Address - Street 1:9390 HESPERIA RD
Practice Address - Street 2:SUITE # 7
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3602
Practice Address - Country:US
Practice Address - Phone:760-998-2125
Practice Address - Fax:760-948-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69428261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care