Provider Demographics
NPI:1467257576
Name:IMPACT LIFELINE
Entity type:Organization
Organization Name:IMPACT LIFELINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:314-279-4565
Mailing Address - Street 1:8 LAURELWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4940
Mailing Address - Country:US
Mailing Address - Phone:314-279-4565
Mailing Address - Fax:309-326-4526
Practice Address - Street 1:205 W 11TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2804
Practice Address - Country:US
Practice Address - Phone:314-279-4565
Practice Address - Fax:309-326-4526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-14
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No251F00000XAgenciesHome InfusionGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty