Provider Demographics
NPI:1972176113
Name:IMPACT OUTPATIENT PROGRAM LLC
Entity Type:Organization
Organization Name:IMPACT OUTPATIENT PROGRAM LLC
Other - Org Name:ROBERT ALEXANDER CENTER FOR RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNSBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-439-2248
Mailing Address - Street 1:1200 N BARDSTOWN RD STE A2
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-7669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N BARDSTOWN RD STE A2
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7669
Practice Address - Country:US
Practice Address - Phone:502-439-2248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility