Healthcare Provider Details

I. General information

NPI: 1699011171
Provider Name (Legal Business Name): IMPACT HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8707 W NORTH AVE
WAUWATOSA WI
53226-2723
US

IV. Provider business mailing address

8707 W NORTH AVE
WAUWATOSA WI
53226-2723
US

V. Phone/Fax

Practice location:
  • Phone: 414-803-4585
  • Fax:
Mailing address:
  • Phone: 414-803-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number101528-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number101528-30
License Number StateWI

VIII. Authorized Official

Name: MRS. YVETTE JOHNSON TOWERS
Title or Position: DIRECTOR
Credential: REGISTERED NURSE
Phone: 414-803-4585