Provider Demographics
NPI:1972106771
Name:IMPACT CARE OHIO LLC.
Entity type:Organization
Organization Name:IMPACT CARE OHIO LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-816-7525
Mailing Address - Street 1:1350 W 5TH AVE STE 128
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2907
Mailing Address - Country:US
Mailing Address - Phone:614-816-7525
Mailing Address - Fax:
Practice Address - Street 1:1350 W 5TH AVE STE 128
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2907
Practice Address - Country:US
Practice Address - Phone:614-816-7525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222184Medicaid