Healthcare Provider Details

I. General information

NPI: 1225944853
Provider Name (Legal Business Name): SOULFUL SANCTUARY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BUSSERON ST STE C-1
VINCENNES IN
47591-2903
US

IV. Provider business mailing address

15549 LAKE LAWRENCE RD
LAWRENCEVILLE IL
62439-4722
US

V. Phone/Fax

Practice location:
  • Phone: 812-881-0435
  • Fax: 812-203-4161
Mailing address:
  • Phone: 812-881-0435
  • Fax: 812-203-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. LACI L THORNTON
Title or Position: OWNER
Credential: FNP
Phone: 618-928-1530