Organization
ILLUMINATED DIRECTION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JONATHAN LACEWELL (OWNER)
(919) 452-7931
Entity
Organization
Contact information
Practice address
6116 ROLLING ROAD SUITE 104, SPRINGFIELD, VA 22152
(571) 730-8445
(888) 227-5443
Mailing address
6116 ROLLING ROAD SUITE 104, SPRINGFIELD, VA 22152
(571) 730-8445
(888) 227-5443
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
—
—
Other
Enumeration date
09/05/2017
Last updated
09/05/2017
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