Provider Demographics
NPI:1679184980
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:
Authorized Official - Last Name:LACEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-450-6446
Mailing Address - Street 1:1903 PASS RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4119
Mailing Address - Country:US
Mailing Address - Phone:228-209-9482
Mailing Address - Fax:601-884-4466
Practice Address - Street 1:1903 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4119
Practice Address - Country:US
Practice Address - Phone:228-209-9482
Practice Address - Fax:601-884-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06307760Medicaid