Provider Demographics
NPI:1790359784
Name:IMPALA CARE HOMES LLC
Entity Type:Organization
Organization Name:IMPALA CARE HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MUGOMOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-910-4181
Mailing Address - Street 1:444 W COMMERCE STREET
Mailing Address - Street 2:APT 3123
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208
Mailing Address - Country:US
Mailing Address - Phone:469-910-4181
Mailing Address - Fax:
Practice Address - Street 1:444 W COMMERCE STREET
Practice Address - Street 2:APT 3123
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:469-910-4181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities