Provider Demographics
NPI:1396556296
Name:IMPACT
Entity type:Organization
Organization Name:IMPACT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-560-7027
Mailing Address - Street 1:110 S APOPKA AVE
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4837
Mailing Address - Country:US
Mailing Address - Phone:352-560-7027
Mailing Address - Fax:
Practice Address - Street 1:110 S APOPKA AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4837
Practice Address - Country:US
Practice Address - Phone:352-560-7027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)