Provider Demographics
NPI:1619285756
Name:IMPACT CAROLINA SERVICES, INC
Entity Type:Organization
Organization Name:IMPACT CAROLINA SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEDOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-405-1617
Mailing Address - Street 1:2848 QUEEN CITY DR STE G
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2739
Mailing Address - Country:US
Mailing Address - Phone:704-405-1617
Mailing Address - Fax:704-405-1619
Practice Address - Street 1:2848 QUEEN CITY DR STE G
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2739
Practice Address - Country:US
Practice Address - Phone:704-405-1617
Practice Address - Fax:704-405-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC795101YA0400X
NC5171101YP2500X
NCC0016641041C0700X
NCNC 2005-003912084P0800X
NC0600071363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006650Medicaid
NC2347954Medicare PIN