Provider Demographics
NPI:1780135681
Name:IMPACT CAROLINA SERVICES,INC
Entity type:Organization
Organization Name:IMPACT CAROLINA SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEDOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-732-2006
Mailing Address - Street 1:106 DOCTORS PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOGER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28092-0000
Mailing Address - Country:US
Mailing Address - Phone:704-732-2006
Mailing Address - Fax:704-732-0303
Practice Address - Street 1:1006 UNION ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0000
Practice Address - Country:US
Practice Address - Phone:704-864-8775
Practice Address - Fax:980-225-0549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC795101YA0400X
NCCD078731041C0700X
NCNC1809906363LP0808X
NCC005215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918094Medicaid
NC6008555Medicaid
NC6008555Medicaid