MEDICARE: PROJECT IMPACT FT.IN 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	251S00000X	Community/Behavioral Health Agency

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	:	1528203437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROJECT IMPACT FT.IN INC.

Provider Business Mailing Address
First Line	:	2200 LAKE AVE STE 105
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5365
Country	:	US
Telephone Number	:	260-426-0646
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 LAKE AVE STE 105
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5365
Country	:	US
Telephone Number	:	260-426-0646
Fax Number	:

Authorized Official
Title or Position	:	OFFICER MANAGER
Name	:	MR. KEVIN THOMAS
Credential	:
Telephone Number	:	260-426-0646

Provider Enumeration Date	:	12/05/2008
Last Update Date	:	12/05/2008

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