Provider Demographics
NPI:1700342003
Name:IMPACTLEX, LLC
Entity Type:Organization
Organization Name:IMPACTLEX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-489-9287
Mailing Address - Street 1:500 HORTON CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1075
Mailing Address - Country:US
Mailing Address - Phone:859-276-0481
Mailing Address - Fax:972-616-6144
Practice Address - Street 1:500 HORTON CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1075
Practice Address - Country:US
Practice Address - Phone:859-276-0481
Practice Address - Fax:972-616-6144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100056370OtherMEDICAID PROVIDER NUMBER