=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619659232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT LIVES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2023
-----------------------------------------------------
Last Update Date | 03/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 S MOPAC EXPY STE 300
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-920-0043
-----------------------------------------------------
Fax | 512-375-3122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 S MOPAC EXPY STE 300
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-920-0043
-----------------------------------------------------
Fax | 512-375-3122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AMBR
-----------------------------------------------------
Name | MR. RAOUL LIBAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 571-474-8383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------