MEDICARE: LIGHTHOUSE CMHC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1427277946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE CMHC

Provider Business Mailing Address
First Line	:	1704 NW 7TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-3502
Country	:	US
Telephone Number	:	305-541-2600
Fax Number	:	305-541-2222

Provider Business Practice Location Address
First Line	:	1704 NW 7TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-3502
Country	:	US
Telephone Number	:	305-541-2600
Fax Number	:	305-541-2222

Authorized Official
Title or Position	:	CEO
Name	:	MR. MICHAEL A MENDOZA
Credential	:
Telephone Number	:	305-541-2600

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	04/15/2008

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Directions to “LIGHTHOUSE CMHC ” Practice Location

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