MEDICARE: IMPACT YOUTH AND FAMILY SERVICES, INC.

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL-051-146	NC

General Provider Information

NPI Number	:	1609926575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT YOUTH AND FAMILY SERVICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 157
Second Line	:
City	:	WILLOW SPRING
State	:	NC
Zip	:	27592-0157
Country	:	US
Telephone Number	:	919-639-3625
Fax Number	:	888-470-3543

Provider Business Practice Location Address
First Line	:	109 DEER FARM LN
Second Line	:
City	:	WILLOW SPRING
State	:	NC
Zip	:	27592-8505
Country	:	US
Telephone Number	:	919-639-3625
Fax Number	:	888-470-3543

Authorized Official
Title or Position	:	CEO
Name	:	LARRY BARTHER
Credential	:
Telephone Number	:	919-639-3625

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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