Provider Demographics
NPI:1093304842
Name:FAITH IMPACT CENTER LLC
Entity Type:Organization
Organization Name:FAITH IMPACT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LASANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-735-0469
Mailing Address - Street 1:7055 E LAKE MEAD BLVD APT 2129
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-1118
Mailing Address - Country:US
Mailing Address - Phone:725-735-0469
Mailing Address - Fax:
Practice Address - Street 1:7055 E LAKE MEAD BLVD APT 2129
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-1118
Practice Address - Country:US
Practice Address - Phone:725-735-0469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health