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General NPI Number Information
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NPI Number | 1972176113
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Entity Type | Organization
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Legal Business Name | IMPACT OUTPATIENT PROGRAM LLC
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Dates
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Enumeration Date | 07/23/2021
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 1200 N BARDSTOWN RD STE A2
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City | MT WASHINGTON
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State | KY
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Zip | 40047-7669
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Country | US
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Telephone | 502-439-2248
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 N BARDSTOWN RD STE A2
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City | MT WASHINGTON
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State | KY
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Zip | 40047-7669
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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 | MANAGER
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Name | BRIAN THORNSBERRY
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Credential |
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Telephone | 502-439-2248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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