Provider Demographics
NPI:1821069493
Name:IMPACTLIFE
Entity Type:Organization
Organization Name:IMPACTLIFE
Other - Org Name:MISSISSIPPI VALLEY REGIONAL BLOOD CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-823-4109
Mailing Address - Street 1:5500 LAKEVIEW PARKWAY
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-5401
Mailing Address - Fax:563-823-4150
Practice Address - Street 1:5500 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3481
Practice Address - Country:US
Practice Address - Phone:563-359-5401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16D0387118291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0243113Medicaid
15614Medicare ID - Type Unspecified