Healthcare Provider Details

I. General information

NPI: 1770324469
Provider Name (Legal Business Name): IMPACT4LIFE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4337 E 30TH ST
INDIANAPOLIS IN
46218-3103
US

IV. Provider business mailing address

4337 E 30TH ST
INDIANAPOLIS IN
46218-3103
US

V. Phone/Fax

Practice location:
  • Phone: 317-517-3713
  • Fax:
Mailing address:
  • Phone: 317-517-3713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA ANN GERMANY
Title or Position: CEO
Credential:
Phone: 317-517-3713