Provider Demographics
NPI:1609286145
Name:ILLUMINATED DIRECTION
Entity Type:Organization
Organization Name:ILLUMINATED DIRECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DALANDISH
Authorized Official - Last Name:LACEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-452-7931
Mailing Address - Street 1:2628 CAMELLIA DR
Mailing Address - Street 2:APT C
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2054
Mailing Address - Country:US
Mailing Address - Phone:919-452-7931
Mailing Address - Fax:888-227-5443
Practice Address - Street 1:800 N MANGUM ST STE 104
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2260
Practice Address - Country:US
Practice Address - Phone:919-450-6446
Practice Address - Fax:888-227-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization