MEDICARE: IMPEL MANAGEMENT SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1023065174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPEL MANAGEMENT SERVICES, LLC

Provider Business Mailing Address
First Line	:	9003 AIRPORT FWY
Second Line	:	SUITE 300
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-7770
Country	:	US
Telephone Number	:	817-849-8296
Fax Number	:	817-514-5246

Provider Business Practice Location Address
First Line	:	1735 KELLER SPRINGS RD
Second Line	:	SUITE 100
City	:	CARROLLTON
State	:	TX
Zip	:	75006-2962
Country	:	US
Telephone Number	:	817-849-8296
Fax Number	:	817-514-5246

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	PAMELA KINNEY GRAYSON
Credential	:	M.B.A.
Telephone Number	:	817-514-5258

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	02/13/2008

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