Provider Demographics
NPI:1154164077
Name:RESIDENTIAL IMPACT SERVICES LLC
Entity type:Organization
Organization Name:RESIDENTIAL IMPACT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JARQUES
Authorized Official - Middle Name:DORRELL
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-372-7330
Mailing Address - Street 1:4417 TEMPLAR DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3925
Mailing Address - Country:US
Mailing Address - Phone:757-372-7330
Mailing Address - Fax:
Practice Address - Street 1:2715 CAMPOSTELLA RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-3656
Practice Address - Country:US
Practice Address - Phone:757-372-7330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty