Healthcare Provider Details

I. General information

NPI: 1467996702
Provider Name (Legal Business Name): ILLUMINATED HEARTS PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 FORD RD SUITE 104E
PHILADELPHIA PA
19131-2039
US

IV. Provider business mailing address

3900 FORD RD SUITE 104E
PHILADELPHIA PA
19131-2039
US

V. Phone/Fax

Practice location:
  • Phone: 610-324-7807
  • Fax: 215-921-6715
Mailing address:
  • Phone: 610-324-7807
  • Fax: 215-921-6715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KIONNA PERRY
Title or Position: PRESIDENT
Credential:
Phone: 610-324-7807