Provider Demographics
NPI:1538325436
Name:IMPACT COMMUNITY AND COORDINATED SERVICES, LLC
Entity Type:Organization
Organization Name:IMPACT COMMUNITY AND COORDINATED SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TOWANDA
Authorized Official - Middle Name:RAWLS
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-471-8888
Mailing Address - Street 1:2605 CARVER ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2720
Mailing Address - Country:US
Mailing Address - Phone:919-471-8888
Mailing Address - Fax:919-471-8888
Practice Address - Street 1:2605 CARVER ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2720
Practice Address - Country:US
Practice Address - Phone:919-471-8888
Practice Address - Fax:919-471-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X, 251C00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services