Provider Demographics
NPI:1891085247
Name:ILLUMI-NATION CARE HOME
Entity Type:Organization
Organization Name:ILLUMI-NATION CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CNA, MT
Authorized Official - Phone:252-641-0020
Mailing Address - Street 1:7806 HWY 42 EAST
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886
Mailing Address - Country:US
Mailing Address - Phone:252-641-0020
Mailing Address - Fax:
Practice Address - Street 1:7806 HWY 42 EAST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886
Practice Address - Country:US
Practice Address - Phone:252-641-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-033-114320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities