MEDICARE: LIFE IMPACT REHABILITATION 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1962100818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE IMPACT REHABILITATION SERVICES, LLC

Provider Business Mailing Address
First Line	:	2807 N PARHAM RD STE 390
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23294-4410
Country	:	US
Telephone Number	:	804-402-1189
Fax Number	:

Provider Business Practice Location Address
First Line	:	2807 N PARHAM RD STE 390
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23294-4410
Country	:	US
Telephone Number	:	804-402-1189
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LETERRIAS ANDREWS
Credential	:
Telephone Number	:	804-402-1189

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	04/04/2023

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