Impact Community Health Organization

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

Legal business name

IMPACT COMMUNITY HEALTH ORGANIZATION

Practice address

3581 Main St Ste 103
College Park, GA 30337-2623

Phone

(704) 315-3895

NPI assigned

Nov 12, 2021

Organization subpart

No

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

Authorized official

Name

Mr. Xavier Young

Title

Ceo

Phone

(704) 315-3895

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Locations

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

{
    "created_epoch": "1636675200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1636675200000",
    "number": "1780340950",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1905 JOHN CALVIN AVE",
            "city": "COLLEGE PARK",
            "state": "GA",
            "postal_code": "303372517",
            "telephone_number": "704-315-3895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3581 MAIN ST STE 103",
            "city": "COLLEGE PARK",
            "state": "GA",
            "postal_code": "303372623",
            "telephone_number": "704-315-3895"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT COMMUNITY HEALTH ORGANIZATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-12",
        "last_updated": "2021-11-12",
        "certification_date": "2021-11-12",
        "status": "A",
        "authorized_official_last_name": "YOUNG",
        "authorized_official_first_name": "XAVIER",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "704-315-3895",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7043153895",
            "state": "GA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "impactcommunityhealth.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Medical Records",
            "address_1": "3581 Main St",
            "city": "College Park",
            "state": "GA",
            "country_code": "US",
            "postal_code": "303372623",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2021; 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.