Provider Demographics
NPI:1467852996
Name:ILUMINA LIFE CENTER, P.C.
Entity Type:Organization
Organization Name:ILUMINA LIFE CENTER, P.C.
Other - Org Name:REGENERATIVE SPINE AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:FLORENTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-467-4055
Mailing Address - Street 1:247 YORK RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-3157
Mailing Address - Country:US
Mailing Address - Phone:814-467-4055
Mailing Address - Fax:814-254-4092
Practice Address - Street 1:211 GRANITE RUN DR STE 221
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601
Practice Address - Country:US
Practice Address - Phone:814-467-4055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain