=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053775528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUMINATED HEARTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2016
-----------------------------------------------------
Last Update Date | 04/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 FORD RD STE 104E
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-921-6624
-----------------------------------------------------
Fax | 215-921-6715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 FORD RD STE 104E
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-921-6624
-----------------------------------------------------
Fax | 215-921-6715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO FOUNDER
-----------------------------------------------------
Name | KIONNA PERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-324-7807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 28383601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------