MEDICARE: MAJOR IMPACT, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	2036AD2405-01	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407211535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAJOR IMPACT, INC.

Provider Business Mailing Address
First Line	:	1960 VELASCO ST
Second Line	:	SUITE J-2
City	:	FORT MYERS
State	:	FL
Zip	:	33916-2761
Country	:	US
Telephone Number	:	239-226-4357
Fax Number	:	239-226-4352

Provider Business Practice Location Address
First Line	:	1960 VELASCO ST
Second Line	:	SUITE J-2
City	:	FORT MYERS
State	:	FL
Zip	:	33916-2761
Country	:	US
Telephone Number	:	239-226-4357
Fax Number	:	239-226-4352

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

Provider Enumeration Date	:	12/16/2015
Last Update Date	:	12/16/2015

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