Provider Demographics
NPI:1699589010
Name:IMPACT LIFE RESIDENTIAL CARE
Entity type:Organization
Organization Name:IMPACT LIFE RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUFUNMI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-833-6052
Mailing Address - Street 1:3203 MAURY ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224
Mailing Address - Country:US
Mailing Address - Phone:804-833-6052
Mailing Address - Fax:
Practice Address - Street 1:3203 MAURY STREET
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224
Practice Address - Country:US
Practice Address - Phone:804-833-6052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities