Provider Demographics
NPI:1033943949
Name:ILLUM RESIDENTIAL CARE, INC.
Entity type:Organization
Organization Name:ILLUM RESIDENTIAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-476-9527
Mailing Address - Street 1:625 MOORINGS AVE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5613
Mailing Address - Country:US
Mailing Address - Phone:470-476-9527
Mailing Address - Fax:
Practice Address - Street 1:625 MOORINGS AVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5613
Practice Address - Country:US
Practice Address - Phone:470-476-9527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No174200000XOther Service ProvidersMeals
No342000000XTransportation ServicesTransportation Network Company