Healthcare Provider Details

I. General information

NPI: 1891085247
Provider Name (Legal Business Name): ILLUMI-NATION CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7806 HWY 42 EAST
TARBORO NC
27886
US

IV. Provider business mailing address

7806 HWY 42 EAST
TARBORO NC
27886
US

V. Phone/Fax

Practice location:
  • Phone: 252-641-0020
  • Fax:
Mailing address:
  • Phone: 252-641-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-033-114
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-033-114
License Number StateNC

VIII. Authorized Official

Name: MS. MARY ELIZABETH HYMAN
Title or Position: OWNER
Credential: CNA, MT
Phone: 252-641-0020