Provider Demographics
NPI:1699011171
Name:IMPACT HEALTH
Entity Type:Organization
Organization Name:IMPACT HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON TOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:414-803-4585
Mailing Address - Street 1:8707 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2723
Mailing Address - Country:US
Mailing Address - Phone:414-803-4585
Mailing Address - Fax:
Practice Address - Street 1:8707 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2723
Practice Address - Country:US
Practice Address - Phone:414-803-4585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101528-30251E00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073805255Medicaid