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General NPI Number Information
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NPI Number | 1508182106
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Entity Type | Organization
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Legal Business Name | IMPACT COMMUNITY SERVICES, LLC
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Dates
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Enumeration Date | 04/08/2010
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Last Update Date | 04/08/2010
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Provider Practice Location Address
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Address Line | 5366 SANTA ROSA AVE
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City | SPARKS
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State | NV
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Zip | 89436-3648
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Country | US
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Telephone | 775-354-2421
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Fax | 775-348-6063
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Provider Business Mailing Address
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Address Line | 5366 SANTA ROSA AVE
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City | SPARKS
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State | NV
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Zip | 89436-3648
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Country | US
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Telephone | 775-354-2421
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Fax | 775-348-6063
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MR. ANTHONY RAY DIQUARTO
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Credential | B.A.
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Telephone | 775-351-7057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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