Provider Demographics
NPI:1992027049
Name:IMPAQ REHABILITATION SERVICESAN
Entity Type:Organization
Organization Name:IMPAQ REHABILITATION SERVICESAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JAN-MICHAEL
Authorized Official - Middle Name:RIVERA
Authorized Official - Last Name:NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-396-9495
Mailing Address - Street 1:5341 EGGERS DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7143
Mailing Address - Country:US
Mailing Address - Phone:510-396-9495
Mailing Address - Fax:
Practice Address - Street 1:178 DENSLOWE DR
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-2035
Practice Address - Country:US
Practice Address - Phone:415-548-0000
Practice Address - Fax:415-333-6231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8113310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility