1114217890 NPI number — IMPAC

Table of content: (NPI 1114217890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114217890 NPI number — IMPAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPAC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
I.M.P.A.C. BY ALTERNATIVE HOME CARE SPECIALISTS, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114217890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 ERASTE LANDRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70506-3046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-0545
Provider Business Mailing Address Fax Number:
337-233-2490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1531 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70506-1825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-233-0545
Provider Business Practice Location Address Fax Number:
337-233-2490
Provider Enumeration Date:
04/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KEPHART
Authorized Official First Name:
CARL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
337-233-0545

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2132172 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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