Healthcare Provider Details

I. General information

NPI: 1144490053
Provider Name (Legal Business Name): LIGHTHOUSE HEALTHCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 SANTA ANA BLVD S
LOS ANGELES CA
90059-1350
US

IV. Provider business mailing address

2222 SANTA ANA BLVD S
LOS ANGELES CA
90059-1350
US

V. Phone/Fax

Practice location:
  • Phone: 323-564-4461
  • Fax: 323-569-9565
Mailing address:
  • Phone: 323-564-4461
  • Fax: 323-569-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number940000071
License Number StateCA

VIII. Authorized Official

Name: MR. LIAB GREENSPOON
Title or Position: OWNER
Credential:
Phone: 323-569-9565