Provider Demographics
NPI:1558015115
Name:SHINING NEW LIGHT LLC
Entity Type:Organization
Organization Name:SHINING NEW LIGHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING CHIEF ADMIN. OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-600-3507
Mailing Address - Street 1:4050 E GREENWAY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4050 E GREENWAY RD STE 4
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4700
Practice Address - Country:US
Practice Address - Phone:630-900-7568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health