Provider Demographics
NPI:1013179902
Name:ILLUME FERTILITY, PLLC
Entity Type:Organization
Organization Name:ILLUME FERTILITY, PLLC
Other - Org Name:AMBULATORY SURGICAL CENTER AT REPRODUCTIVE MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGIERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-750-7400
Mailing Address - Street 1:761 MAIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-750-7400
Mailing Address - Fax:
Practice Address - Street 1:761 MAIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1080
Practice Address - Country:US
Practice Address - Phone:203-750-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0006X
CT0320261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical