Organization
IMPACT LIFE GROUP HOME LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEBOLISA S ILUKWE (DIRECTOR)
(704) 749-4556
Entity
Organization
Contact information
Practice address
6412 BALTRAY RD, CHARLOTTE, NC 28278-6640
(704) 749-4556
Mailing address
6412 BALTRAY RD, CHARLOTTE, NC 28278-6640
(704) 749-4556
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
—
Other
Enumeration date
02/03/2026
Last updated
02/03/2026
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