Healthcare Provider Details

I. General information

NPI: 1114217890
Provider Name (Legal Business Name): IMPAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-1825
US

IV. Provider business mailing address

1220 ERASTE LANDRY RD
LAFAYETTE LA
70506-3046
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-0545
  • Fax: 337-233-2490
Mailing address:
  • Phone: 337-233-0545
  • Fax: 337-233-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CARL KEPHART
Title or Position: CEO
Credential:
Phone: 337-233-0545