Healthcare Provider Details

I. General information

NPI: 1295101715
Provider Name (Legal Business Name): ILUMINA LIFE CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 TIRE HILL RD SUITE 100
JOHNSTOWN PA
15905-7311
US

IV. Provider business mailing address

136 JAYCEE DR SUITE 10
JOHNSTOWN PA
15904-3650
US

V. Phone/Fax

Practice location:
  • Phone: 814-467-4055
  • Fax: 814-262-9816
Mailing address:
  • Phone: 814-467-4055
  • Fax: 814-626-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: FLORENTINA MAYKO
Title or Position: CEO
Credential:
Phone: 814-467-4055