Provider Demographics
NPI:1386198877
Name:ILLUMINATION FOUNDATION OF NORTH CAROLINA
Entity Type:Organization
Organization Name:ILLUMINATION FOUNDATION OF NORTH CAROLINA
Other - Org Name:IFNC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-239-8374
Mailing Address - Street 1:2540 ANNECY DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-2323
Mailing Address - Country:US
Mailing Address - Phone:980-239-8374
Mailing Address - Fax:
Practice Address - Street 1:2540 ANNECY DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-2323
Practice Address - Country:US
Practice Address - Phone:980-239-8374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC201601100142-I251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable