MEDICARE: LIGHTHOUSE OF HOPE & HEALING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073135620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE OF HOPE & HEALING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 105755
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65110-5755
Country	:	US
Telephone Number	:	573-690-7919
Fax Number	:	573-636-7771

Provider Business Practice Location Address
First Line	:	1026 NORTHEAST DR STE B
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-2517
Country	:	US
Telephone Number	:	573-690-7919
Fax Number	:	573-636-7771

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTINA L SANNI
Credential	:
Telephone Number	:	573-690-7919

Provider Enumeration Date	:	05/16/2020
Last Update Date	:	05/16/2020

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