Healthcare Provider Details

I. General information

NPI: 1962100818
Provider Name (Legal Business Name): LIFE IMPACT REHABILITATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 MILLRIDGE PKWY E STE 220
MIDLOTHIAN VA
23112-4857
US

IV. Provider business mailing address

4920 MILLRIDGE PKWY E STE 220
MIDLOTHIAN VA
23112-4857
US

V. Phone/Fax

Practice location:
  • Phone: 804-402-1189
  • Fax:
Mailing address:
  • Phone: 804-402-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LETERRIAS ANDREWS
Title or Position: CEO
Credential:
Phone: 804-402-1189