Provider Demographics
NPI:1982906558
Name:IMPACT SPECIALIZED TRANSPORT
Entity Type:Organization
Organization Name:IMPACT SPECIALIZED TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-707-5311
Mailing Address - Street 1:1646 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6028
Mailing Address - Country:US
Mailing Address - Phone:704-707-5311
Mailing Address - Fax:
Practice Address - Street 1:1646 EASTWOOD DR
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6028
Practice Address - Country:US
Practice Address - Phone:704-707-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22469655343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)