Healthcare Provider Details

I. General information

NPI: 1285931329
Provider Name (Legal Business Name): LIGHTHOUSE GENERAL PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 TORRANCE BLVD SUITE 104
TORRANCE CA
90503-4812
US

IV. Provider business mailing address

3661 TORRANCE BLVD SUITE 104
TORRANCE CA
90503-4812
US

V. Phone/Fax

Practice location:
  • Phone: 310-953-0020
  • Fax: 310-953-0019
Mailing address:
  • Phone: 310-953-0020
  • Fax: 310-953-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A9943
License Number StateCA

VIII. Authorized Official

Name: DR. LYDIA TALAAT ELIAS
Title or Position: DIRECTOR
Credential: D.O.
Phone: 310-953-0020