MEDICARE: IMPACT INTERVENTIONS BEHAVIORAL HEALTH SERVICES LLC

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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1528480670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT INTERVENTIONS BEHAVIORAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	8109 IVY HOLLOW CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89143-5168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8109 IVY HOLLOW CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89143-5168
Country	:	US
Telephone Number	:	702-573-5813
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DARRELL TELLIS
Credential	:
Telephone Number	:	702-573-5813

Provider Enumeration Date	:	01/09/2014
Last Update Date	:	01/09/2014

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