Provider Demographics
NPI:1275023590
Name:IMPATEX
Entity Type:Organization
Organization Name:IMPATEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MBOCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-908-3349
Mailing Address - Street 1:6300 EAGLE LAKE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1645
Mailing Address - Country:US
Mailing Address - Phone:817-908-3349
Mailing Address - Fax:
Practice Address - Street 1:6300 EAGLE LAKE CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179
Practice Address - Country:US
Practice Address - Phone:817-908-3349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services