Provider Demographics
NPI:1184378648
Name:IMPACT HEALTH & WELLNESS LAB, LLC
Entity type:Organization
Organization Name:IMPACT HEALTH & WELLNESS LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:337-884-4934
Mailing Address - Street 1:3443 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-1006
Mailing Address - Country:US
Mailing Address - Phone:337-884-4934
Mailing Address - Fax:
Practice Address - Street 1:3443 WATERVIEW DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-1006
Practice Address - Country:US
Practice Address - Phone:337-884-4934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory