Provider Demographics
NPI:1215682505
Name:IMPACT HOME CARE SERVICES LLC
Entity type:Organization
Organization Name:IMPACT HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-415-7665
Mailing Address - Street 1:6700 BOWDEN RD UNIT 1104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3672
Mailing Address - Country:US
Mailing Address - Phone:904-415-7665
Mailing Address - Fax:
Practice Address - Street 1:4720 SALISBURY RD
Practice Address - Street 2:UNIT 110
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6101
Practice Address - Country:US
Practice Address - Phone:904-415-7665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020792700Medicaid