Provider Demographics
NPI:1558018432
Name:IMPACT LIFE
Entity Type:Organization
Organization Name:IMPACT LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOMENICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSONTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-465-0019
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-5269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4973 BOYCE RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-6637
Practice Address - Country:US
Practice Address - Phone:302-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder