Provider Demographics
NPI:1528203437
Name:PROJECT IMPACT FT.IN INC.
Entity Type:Organization
Organization Name:PROJECT IMPACT FT.IN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-426-0646
Mailing Address - Street 1:2200 LAKE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5365
Mailing Address - Country:US
Mailing Address - Phone:260-426-0646
Mailing Address - Fax:
Practice Address - Street 1:2200 LAKE AVE STE 105
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5365
Practice Address - Country:US
Practice Address - Phone:260-426-0646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200843270Medicaid