Organization
ILLUMINATED DIRECTION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JONATHAN LACEWELL (OWNER)
(919) 450-6446
Entity
Organization
Contact information
Practice address
1903 PASS RD, BILOXI, MS 39531-4119
(228) 209-9482
(601) 884-4466
Mailing address
1903 PASS RD, BILOXI, MS 39531-4119
(228) 209-9482
(601) 884-4466
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06307760
—
MS
Enumeration date
08/11/2020
Last updated
01/08/2021
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