=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447128087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT COMMUNITY ECONOMIC DEVELOPMENT CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2025
-----------------------------------------------------
Last Update Date | 10/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2404 LINCOLN WAY W
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46628-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-366-0801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 TOLEDO RD
-----------------------------------------------------
City | ELKHART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46516-5771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-216-3497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. EDWIN A NEWSOME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 574-216-3497
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------