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Organization
ILLUM RESIDENTIAL CARE, INC.
Active
Organization
ILLUM RESIDENTIAL CARE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RAVEN PITTMAN (CHIEF FINANCIAL OFFICER)
(470) 476-9527
Entity
Organization
Contact information
Practice address
625 MOORINGS AVE, MCDONOUGH, GA 30253-5613
(470) 476-9527
Mailing address
625 MOORINGS AVE, MCDONOUGH, GA 30253-5613
(470) 476-9527
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
NULL
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
—
NULL
101YM0800X
Mental Health Counselor
—
—
174200000X
Meals Provider
—
NULL
251E00000X
Home Health Agency
Primary
—
NULL
342000000X
Transportation Network Company
—
NULL
Other
Enumeration date
09/02/2024
Last updated
09/02/2024
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