Provider Demographics
NPI:1144659830
Name:RADIANCE LIGHT SYSTEMS, LLC
Entity type:Organization
Organization Name:RADIANCE LIGHT SYSTEMS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CISSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-819-1432
Mailing Address - Street 1:2145 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062
Mailing Address - Country:US
Mailing Address - Phone:770-565-8266
Mailing Address - Fax:
Practice Address - Street 1:2145 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-0821
Practice Address - Country:US
Practice Address - Phone:770-565-8266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA140922261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service