MEDICARE: GEORGIA LIONS LIGHTHOUSE FOUNDATION

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	251K00000X	Public Health or Welfare Agency
2	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1518251818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA LIONS LIGHTHOUSE FOUNDATION

Provider Business Mailing Address
First Line	:	5582 PEACHTREE RD
Second Line	:
City	:	CHAMBLEE
State	:	GA
Zip	:	30341-2383
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5582 PEACHTREE RD
Second Line	:
City	:	CHAMBLEE
State	:	GA
Zip	:	30341-2383
Country	:	US
Telephone Number	:	404-325-3630
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. CHRISTINA LENNON
Credential	:	M.A.
Telephone Number	:	404-325-3630

Provider Enumeration Date	:	06/03/2011
Last Update Date	:	06/03/2011

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