Provider Demographics
NPI:1194436337
Name:IMPACT HOME LLC
Entity type:Organization
Organization Name:IMPACT HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NKECHI
Authorized Official - Middle Name:H
Authorized Official - Last Name:ADENIJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-205-8111
Mailing Address - Street 1:13615 W SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-3313
Mailing Address - Country:US
Mailing Address - Phone:623-205-8111
Mailing Address - Fax:
Practice Address - Street 1:13615 W SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-3313
Practice Address - Country:US
Practice Address - Phone:623-205-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care