Provider Demographics
NPI:1073863056
Name:ILLUMINATION FOUNDATION
Entity type:Organization
Organization Name:ILLUMINATION FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:POOJA
Authorized Official - Middle Name:
Authorized Official - Last Name:BHALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, RN
Authorized Official - Phone:949-502-0339
Mailing Address - Street 1:2871 PULLMAN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5713
Mailing Address - Country:US
Mailing Address - Phone:949-273-0555
Mailing Address - Fax:
Practice Address - Street 1:3535 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-2821
Practice Address - Country:US
Practice Address - Phone:949-273-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes385H00000XRespite Care FacilityRespite Care
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty
No251X00000XAgenciesSupports Brokerage
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10055Medicaid