MEDICARE: IMPACT HEALTH

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	251J00000X	Nursing Care Agency	101528-30	WI
2	251E00000X	Home Health Agency	101528-30	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699011171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT HEALTH

Provider Business Mailing Address
First Line	:	8707 W NORTH AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2723
Country	:	US
Telephone Number	:	414-803-4585
Fax Number	:

Provider Business Practice Location Address
First Line	:	8707 W NORTH AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2723
Country	:	US
Telephone Number	:	414-803-4585
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. YVETTE JOHNSON TOWERS
Credential	:	REGISTERED NURSE
Telephone Number	:	414-803-4585

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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Directions to “IMPACT HEALTH ” Practice Location

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