Healthcare Provider Details

I. General information

NPI: 1881152031
Provider Name (Legal Business Name): 200 LIGHTHOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LIGHTHOUSE AVE
PACIFIC GROVE CA
93950-3022
US

IV. Provider business mailing address

200 LIGHTHOUSE AVE
PACIFIC GROVE CA
93950-3022
US

V. Phone/Fax

Practice location:
  • Phone: 931-375-2695
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD MARTIN
Title or Position: MANAGER
Credential:
Phone: 619-402-3044