=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407073125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT FAMILY CARE HOME INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 RED HOLLY DR
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330-0389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-708-5565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 RED HOLLY DR
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330-0389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-708-5565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SYVILLA R PRISTELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-708-5565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------