Provider Demographics
NPI:1376789925
Name:IMPACT CAROLINA SERVICES INC.
Entity Type:Organization
Organization Name:IMPACT CAROLINA SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:OLATUNDE
Authorized Official - Last Name:ADEDOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-533-0277
Mailing Address - Street 1:3080 JAMESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-6056
Mailing Address - Country:US
Mailing Address - Phone:704-533-0277
Mailing Address - Fax:704-864-3355
Practice Address - Street 1:106 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4406
Practice Address - Country:US
Practice Address - Phone:704-533-0277
Practice Address - Fax:704-685-5937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC795101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111767Medicaid