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General NPI Number Information
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NPI Number | 1437317682
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Entity Type | Organization
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Legal Business Name | IMPACT
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Dates
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Enumeration Date | 05/23/2008
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Last Update Date | 05/27/2008
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Provider Practice Location Address
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Address Line | 152 E MAIN ST STE 106
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City | RIGBY
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State | ID
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Zip | 83442-5268
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Country | US
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Telephone | 208-745-7831
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Fax | 208-745-0658
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Provider Business Mailing Address
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Address Line | PO BOX 2106
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City | IDAHO FALLS
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State | ID
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Zip | 83403-2106
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Country | US
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Telephone | 208-745-7831
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Fax | 208-745-0658
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Authorized Official
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Title or Position | OWNER/LSW
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Name | BRUCE HAMPTON
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Credential | LSW
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Telephone | 208-522-8899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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