Provider Demographics
NPI:1326710443
Name:IMPACT LIVES HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:IMPACT LIVES HEALTH SERVICES, LLC
Other - Org Name:IMPACT LIVES HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-963-2602
Mailing Address - Street 1:PO BOX 11462
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-0462
Mailing Address - Country:US
Mailing Address - Phone:410-963-2602
Mailing Address - Fax:
Practice Address - Street 1:1045 TAYLOR AVE STE 206
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-8316
Practice Address - Country:US
Practice Address - Phone:443-963-2602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)