Provider Demographics
NPI:1790558690
Name:LIFE IMPACT LLC
Entity Type:Organization
Organization Name:LIFE IMPACT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-325-7479
Mailing Address - Street 1:8325 FINWORTH LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-3872
Mailing Address - Country:US
Mailing Address - Phone:804-549-1585
Mailing Address - Fax:804-562-3736
Practice Address - Street 1:8325 FINWORTH LN
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23237-3872
Practice Address - Country:US
Practice Address - Phone:804-549-1585
Practice Address - Fax:804-562-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health