Provider Demographics
NPI:1578965604
Name:IMPOWER
Entity Type:Organization
Organization Name:IMPOWER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OYOLA-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:860-083-7230
Mailing Address - Street 1:1065 S KIRKMAN RD
Mailing Address - Street 2:132
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3214
Mailing Address - Country:US
Mailing Address - Phone:860-983-7230
Mailing Address - Fax:
Practice Address - Street 1:587 E STATE ROAD 434
Practice Address - Street 2:SUITE1021
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5201
Practice Address - Country:US
Practice Address - Phone:407-331-8002
Practice Address - Fax:407-331-8659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3120806Medicaid