Healthcare Provider Details

I. General information

NPI: 1609926575
Provider Name (Legal Business Name): IMPACT YOUTH AND FAMILY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 DEER FARM LN
WILLOW SPRING NC
27592-8505
US

IV. Provider business mailing address

PO BOX 157
WILLOW SPRING NC
27592-0157
US

V. Phone/Fax

Practice location:
  • Phone: 919-639-3625
  • Fax: 888-470-3543
Mailing address:
  • Phone: 919-639-3625
  • Fax: 888-470-3543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-051-146
License Number StateNC

VIII. Authorized Official

Name: LARRY BARTHER
Title or Position: CEO
Credential:
Phone: 919-639-3625