Provider Demographics
NPI:1669992400
Name:IMPACT'S TRANSITIONAL LIFE-SKILL CENTER INC
Entity type:Organization
Organization Name:IMPACT'S TRANSITIONAL LIFE-SKILL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-693-5101
Mailing Address - Street 1:909 BRYAN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6145
Mailing Address - Country:US
Mailing Address - Phone:813-693-5101
Mailing Address - Fax:
Practice Address - Street 1:909 BRYAN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6145
Practice Address - Country:US
Practice Address - Phone:813-693-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385H00000XRespite Care FacilityRespite Care