Healthcare Provider Details

I. General information

NPI: 1053775528
Provider Name (Legal Business Name): ILLUMINATED HEARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 215-921-6624
  • Fax: 215-921-6715
Mailing address:
  • Phone: 215-921-6624
  • Fax: 215-921-6715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number28383601
License Number StatePA

VIII. Authorized Official

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