=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699011171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2013
-----------------------------------------------------
Last Update Date | 01/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8707 W NORTH AVE
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-803-4585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8707 W NORTH AVE
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-803-4585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. YVETTE JOHNSON TOWERS
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 414-803-4585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | 101528-30
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 101528-30
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------