Provider Demographics
NPI:1902953474
Name:ILLIUMINATED HOME HEALTH CARE LLC.
Entity Type:Organization
Organization Name:ILLIUMINATED HOME HEALTH CARE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-261-9935
Mailing Address - Street 1:175 CHARLES AVENUE
Mailing Address - Street 2:328
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103
Mailing Address - Country:US
Mailing Address - Phone:952-261-9935
Mailing Address - Fax:651-224-2857
Practice Address - Street 1:175 CHARLES AVE
Practice Address - Street 2:328
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2054
Practice Address - Country:US
Practice Address - Phone:952-261-9935
Practice Address - Fax:651-224-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN904066000305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization