Provider Demographics
NPI:1528480670
Name:IMPACT INTERVENTIONS BEHAVIORAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:IMPACT INTERVENTIONS BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-573-5813
Mailing Address - Street 1:8109 IVY HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-5168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8109 IVY HOLLOW CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89143-5168
Practice Address - Country:US
Practice Address - Phone:702-573-5813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty