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General NPI Number Information
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NPI Number | 1558018432
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Entity Type | Organization
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Legal Business Name | IMPACT LIFE, INC
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Dates
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Enumeration Date | 03/09/2022
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Last Update Date | 03/04/2025
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Provider Practice Location Address
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Address Line | 4973 BOYCE RD
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City | SEAFORD
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State | DE
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Zip | 19973-6637
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Country | US
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Telephone | 302-000-0000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1269
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City | HOCKESSIN
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State | DE
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Zip | 19707-5269
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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 | CEO
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Name | DOMENICA PERSONTI
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Credential |
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Telephone | 302-465-0019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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