Healthcare Provider Details

I. General information

NPI: 1982151676
Provider Name (Legal Business Name): LIGHTHEARTED MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MONTGOMERY ST STE 101
SAN FRANCISCO CA
94111-1022
US

IV. Provider business mailing address

1700 MONTGOMERY ST STE 101
SAN FRANCISCO CA
94111-1022
US

V. Phone/Fax

Practice location:
  • Phone: 415-964-0546
  • Fax: 888-861-2143
Mailing address:
  • Phone: 415-964-0546
  • Fax: 888-861-2143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberC53920
License Number StateCA

VIII. Authorized Official

Name: DR. BRUCE ALLEN ROBERTS
Title or Position: CFO, MEDICAL DIRECTOR
Credential: MD
Phone: 415-964-0546