Provider Demographics
NPI:1487054342
Name:IMPACT LIVING SERVICES
Entity type:Organization
Organization Name:IMPACT LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:WEST
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:434-660-2917
Mailing Address - Street 1:630 WYNDHURST DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-3454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 WYNDHURST DR
Practice Address - Street 2:SUITE F
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-3454
Practice Address - Country:US
Practice Address - Phone:434-533-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-28
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty