Impact Wellness Center LLC

Primary specialty

Comprehensive Outpatient Rehabilitation Facility (CORF)Taxonomy code 261QR0401X

Legal business name

IMPACT WELLNESS CENTER LLC

Practice address

3179 W White Mountain Blvd
Lakeside, AZ 85929-6146

Phone

(615) 720-8088

NPI assigned

Feb 9, 2024

Last updated

May 1, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Charles Wade

Title

Owner

Phone

(615) 720-8088

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1707436800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714521600000",
    "number": "1093579054",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3179 W WHITE MOUNTAIN BLVD",
            "city": "LAKESIDE",
            "state": "AZ",
            "postal_code": "859296146",
            "telephone_number": "615-720-8088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3179 W WHITE MOUNTAIN BLVD",
            "city": "LAKESIDE",
            "state": "AZ",
            "postal_code": "859296146",
            "telephone_number": "615-720-8088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT WELLNESS CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-02-09",
        "last_updated": "2024-05-01",
        "certification_date": "2024-05-01",
        "status": "A",
        "authorized_official_last_name": "WADE",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "615-720-8088"
    },
    "taxonomies": [
        {
            "code": "261QR0401X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Comprehensive Outpatient Rehabilitation Facility (CORF) in Lakeside, AZ
• Providers in Lakeside, AZ by specialty
• Comprehensive Outpatient Rehabilitation Facility (CORF) in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.