Basic Information
| Provider Information | |||||||||
| NPI: | 1942686753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILUMINA LIFE CENTER, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 136 JAYCEE DR | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159043650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144674055 | ||||||||
| FaxNumber: | 8142628161 | ||||||||
| Practice Location | |||||||||
| Address1: | 418 N LOGAN BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BURNHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170091816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172423900 | ||||||||
| FaxNumber: | 7172488590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | MELODY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144674055 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | MD423112 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.