=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134879125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACTFUL RESIDENTIAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2022
-----------------------------------------------------
Last Update Date | 03/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 SEAVEY ST
-----------------------------------------------------
City | WESTBROOK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04092-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-278-6103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8057
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04104-8057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-310-3101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ASSUMPTA MUKABUTERA
-----------------------------------------------------
Credential | MPH, PH.D
-----------------------------------------------------
Telephone | 207-310-3101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------