MEDICARE: MAJOR IMPACT SUPPORT SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center
4	3245S0500X	Children's Substance Abuse Rehabilitation Facility
5	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1093468274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAJOR IMPACT SUPPORT SERVICES, INC

Provider Business Mailing Address
First Line	:	1960 VELASCO ST STE J2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-2761
Country	:	US
Telephone Number	:	239-226-4657
Fax Number	:	239-226-4352

Provider Business Practice Location Address
First Line	:	1960 VELASCO ST STE J2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-2761
Country	:	US
Telephone Number	:	239-226-4657
Fax Number	:	239-226-4352

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CLAYTON LAMBERT MAJOR SR.
Credential	:	MS
Telephone Number	:	239-226-4357

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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