MEDICARE: LASTING IMPRESSIONS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1922938257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASTING IMPRESSIONS LLC

Provider Business Mailing Address
First Line	:	907 BLAZINGWOOD DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-8265
Country	:	US
Telephone Number	:	336-848-9222
Fax Number	:	336-848-9222

Provider Business Practice Location Address
First Line	:	907 BLAZINGWOOD DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-8265
Country	:	US
Telephone Number	:	336-848-9222
Fax Number	:	336-848-9222

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. NICOLE PEGUESE CRUMPTON
Credential	:	QP
Telephone Number	:	336-848-9222

Provider Enumeration Date	:	05/20/2026
Last Update Date	:	05/20/2026

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