Provider Demographics
NPI:1023833654
Name:IVORY HOLOGRAM
Entity type:Organization
Organization Name:IVORY HOLOGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BUSINESS OPERATOR/INVESTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:NJAMBI
Authorized Official - Last Name:KAMAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-610-5403
Mailing Address - Street 1:821 WHITE DAISIES CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 WHITE DAISIES CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2255
Practice Address - Country:US
Practice Address - Phone:919-610-5403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of Service
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty