MEDICARE: IMPACT SUPPORT 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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1720584642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	10602 HEATHER GLEN WAY
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-4279
Country	:	US
Telephone Number	:	203-675-3225
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 FORBES BLVD STE 200-E
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-6312
Country	:	US
Telephone Number	:	203-675-3225
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	AMARA UZOMAH
Credential	:
Telephone Number	:	203-675-3225

Provider Enumeration Date	:	03/30/2018
Last Update Date	:	03/30/2018

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