Healthcare Provider Details

I. General information

NPI: 1205666542
Provider Name (Legal Business Name): IMPACT DAYTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 WOOD DALE DR
DAYTON OH
45414-3838
US

IV. Provider business mailing address

5325 WOOD DALE DR
DAYTON OH
45414-3838
US

V. Phone/Fax

Practice location:
  • Phone: 937-620-7090
  • Fax:
Mailing address:
  • Phone: 937-620-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: KANIKA DIX
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 937-620-3918