Healthcare Provider Details

I. General information

NPI: 1326830514
Provider Name (Legal Business Name): FRESH IMPACT CHURCH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 MAGNOLIA PKWY
MANVEL TX
77578-1800
US

IV. Provider business mailing address

3627 CIBOLO CT
PEARLAND TX
77584-3975
US

V. Phone/Fax

Practice location:
  • Phone: 678-677-4041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: TYRONE LANE
Title or Position: OWNER
Credential:
Phone: 678-677-4041