Provider Demographics
NPI:1265965446
Name:ILLUMINE INTEGRATIVE THERAPEUTICS LLC
Entity type:Organization
Organization Name:ILLUMINE INTEGRATIVE THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-796-2975
Mailing Address - Street 1:20 SANTA ANA LOOP
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9440
Mailing Address - Country:US
Mailing Address - Phone:505-796-2975
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY BLVD NE
Practice Address - Street 2:SUITE 402
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2360
Practice Address - Country:US
Practice Address - Phone:505-796-2975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1339251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health