Provider Demographics
NPI:1861941049
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:O
Authorized Official - Last Name:ADEDOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-732-2006
Mailing Address - Street 1:1006 UNION ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0000
Mailing Address - Country:US
Mailing Address - Phone:704-864-8775
Mailing Address - Fax:980-225-0549
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:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2084P0800X, 363LP0808X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006650Medicaid
NC6006650Medicaid