Healthcare Provider Details

I. General information

NPI: 1023833654
Provider Name (Legal Business Name): IVORY HOLOGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 WHITE DAISIES CT
RALEIGH NC
27610-2255
US

IV. Provider business mailing address

821 WHITE DAISIES CT
RALEIGH NC
27610-2255
US

V. Phone/Fax

Practice location:
  • Phone: 919-610-5403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: DIANA NJAMBI KAMAU
Title or Position: OWNER/BUSINESS OPERATOR/INVESTOR
Credential:
Phone: 984-383-7693