Provider Demographics
NPI:1891476602
Name:ENLIGHTENING GROWTH DDS LLC
Entity Type:Organization
Organization Name:ENLIGHTENING GROWTH DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP
Authorized Official - Prefix:
Authorized Official - First Name:AURIOL
Authorized Official - Middle Name:MURIEL MIDAS
Authorized Official - Last Name:PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:402-208-1937
Mailing Address - Street 1:PO BOX 1144
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51502-1144
Mailing Address - Country:US
Mailing Address - Phone:402-208-1937
Mailing Address - Fax:
Practice Address - Street 1:4609 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68133-4839
Practice Address - Country:US
Practice Address - Phone:402-208-1937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No171W00000XOther Service ProvidersContractorGroup - Single Specialty