MEDICARE: IMPACT HEALTH CARE 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	251E00000X	Home Health Agency	338147	MN

General Provider Information

NPI Number	:	1649441049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT HEALTH CARE SERVICES LLC

Provider Business Mailing Address
First Line	:	6000 BASS LAKE RD
Second Line	:	SUITE 113
City	:	CRYSTAL
State	:	MN
Zip	:	55429-2700
Country	:	US
Telephone Number	:	763-232-4989
Fax Number	:	877-896-4521

Provider Business Practice Location Address
First Line	:	6000 BASS LAKE RD
Second Line	:	SUITE 113
City	:	CRYSTAL
State	:	MN
Zip	:	55429-2700
Country	:	US
Telephone Number	:	763-232-4989
Fax Number	:	877-896-4521

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PHILIP KIMELI LELEI
Credential	:
Telephone Number	:	763-232-4989

Provider Enumeration Date	:	03/13/2008
Last Update Date	:	03/13/2008

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