Healthcare Provider Details

I. General information

NPI: 1619659232
Provider Name (Legal Business Name): IMPACT LIVES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S MOPAC EXPY STE 300
AUSTIN TX
78746-5883
US

IV. Provider business mailing address

901 S MOPAC EXPY STE 300
AUSTIN TX
78746-5883
US

V. Phone/Fax

Practice location:
  • Phone: 512-920-0043
  • Fax: 512-375-3122
Mailing address:
  • Phone: 512-920-0043
  • Fax: 512-375-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: MR. RAOUL LIBAM
Title or Position: AMBR
Credential:
Phone: 571-474-8383