Healthcare Provider Details

I. General information

NPI: 1710204441
Provider Name (Legal Business Name): ILLUME CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6595 N 6000 W
HIGHLAND UT
84003-4720
US

IV. Provider business mailing address

6280 W 9600 N
HIGHLAND UT
84003-9234
US

V. Phone/Fax

Practice location:
  • Phone: 801-216-4800
  • Fax:
Mailing address:
  • Phone: 801-216-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number16410
License Number StateUT

VIII. Authorized Official

Name: JOHANNA SALTER
Title or Position: COO
Credential:
Phone: 801-216-4800