Provider Demographics
NPI:1962022806
Name:ILLUMINATE RECOVERY LLC
Entity Type:Organization
Organization Name:ILLUMINATE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-262-1239
Mailing Address - Street 1:10619 N HAYDEN RD STE A-108
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-8529
Mailing Address - Country:US
Mailing Address - Phone:480-262-1239
Mailing Address - Fax:
Practice Address - Street 1:10619 N HAYDEN RD STE A-108
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-8529
Practice Address - Country:US
Practice Address - Phone:480-262-1239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder