Healthcare Provider Details

I. General information

NPI: 1114768363
Provider Name (Legal Business Name): IMPACT LIFE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7607 BARKBRIDGE RD
CHESTERFIELD VA
23832-8288
US

IV. Provider business mailing address

10482 BALTIMORE AVE PMB 377
BELTSVILLE MD
20705
US

V. Phone/Fax

Practice location:
  • Phone: 804-833-6052
  • Fax:
Mailing address:
  • Phone: 240-467-1127
  • Fax: 132-397-8144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: OLUFUNMI LOLA JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 240-467-1127