1558544742 NPI number — IMPACT KIDS, INC

Table of content: (NPI 1558544742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558544742 NPI number — IMPACT KIDS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPACT KIDS, INC
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:
Provider Other Organization Name Type Code:
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:
1558544742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
451 ARTHUR GODFREY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33140-3503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-672-4464
Provider Business Mailing Address Fax Number:
305-672-4484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 ARTHUR GODFREY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33140-3503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-672-4464
Provider Business Practice Location Address Fax Number:
305-672-4484
Provider Enumeration Date:
12/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STROM
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-672-4464

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT7470 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X , with the licence number: SA8858 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 892667100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".