MEDICARE: LAMPLIGHT VILLAGE 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1093318230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAMPLIGHT VILLAGE LLC

Provider Business Mailing Address
First Line	:	PO BOX 166
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-0166
Country	:	US
Telephone Number	:	417-257-0954
Fax Number	:	417-257-2982

Provider Business Practice Location Address
First Line	:	309 LOCUST ST
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-3906
Country	:	US
Telephone Number	:	417-256-2749
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MICHAEL NEWTON
Credential	:
Telephone Number	:	417-257-0954

Provider Enumeration Date	:	11/19/2020
Last Update Date	:	12/28/2022

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Directions to “LAMPLIGHT VILLAGE LLC ” Practice Location

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