Provider Demographics
NPI:1629311063
Name:IMPACT CAROLINA SERVICES
Entity Type:Organization
Organization Name:IMPACT CAROLINA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:704-732-2006
Mailing Address - Street 1:1552 UNION RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5523
Mailing Address - Country:US
Mailing Address - Phone:704-852-9210
Mailing Address - Fax:704-852-9211
Practice Address - Street 1:1552 UNION RD
Practice Address - Street 2:SUITE C
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5523
Practice Address - Country:US
Practice Address - Phone:704-852-9210
Practice Address - Fax:704-852-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC795101YA0400X
NCC0027281041C0700X
NCNC 93-004722084P0800X
NC5004878363L00000X
NC5004910363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5004910Medicaid
NC6003129Medicaid
NC891036YMedicaid
NC5004878Medicaid
NC6111767Medicaid
NC6111767Medicaid
NC891036YMedicaid
NC5004878Medicaid