=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326646878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT DUI, ILC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2020
-----------------------------------------------------
Last Update Date | 03/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 LIBERTY RD UNIT 104
-----------------------------------------------------
City | ELDERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-7980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-581-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1209 LIBERTY RD UNIT 102
-----------------------------------------------------
City | ELDERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-7980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-581-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DANIEL BRANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-581-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------