MEDICARE: THE LIGHTHOUSE OF LOVE

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	:	1417579749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LIGHTHOUSE OF LOVE

Provider Business Mailing Address
First Line	:	730 W CHEYENNE AVE STE 40
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7849
Country	:	US
Telephone Number	:	702-633-7923
Fax Number	:	702-633-7610

Provider Business Practice Location Address
First Line	:	5060 N 19TH AVE STE 300-28
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-3210
Country	:	US
Telephone Number	:	702-633-7923
Fax Number	:	702-633-7610

Authorized Official
Title or Position	:	OWNER
Name	:	LADONNA KAY WRIGHT TAPPLIN
Credential	:
Telephone Number	:	702-633-7923

Provider Enumeration Date	:	05/08/2020
Last Update Date	:	05/08/2020

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Directions to “THE LIGHTHOUSE OF LOVE ” Practice Location

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