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General NPI Number Information
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NPI Number | 1356254973
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Entity Type | Organization
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Legal Business Name | IMPACT WELLNESS LLC
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Dates
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Enumeration Date | 09/24/2026
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Last Update Date | 09/24/2026
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Provider Practice Location Address
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Address Line | 12420 ROCHFORD LN
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City | JACKSONVILLE
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State | FL
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Zip | 32225-4611
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Country | US
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Telephone | 904-540-4722
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Fax |
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Provider Business Mailing Address
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Address Line | 1005 SOUTHERN HILLS DR
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City | ORANGE PARK
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State | FL
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Zip | 32065-2652
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT OWNER
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Name | CHARLES GILLEY
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Credential |
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Telephone | 904-540-4722
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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