Healthcare Provider Details

I. General information

NPI: 1649767500
Provider Name (Legal Business Name): LIGHTHOUSE COMPANION CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MAIN ST
OLD SAYBROOK CT
06475-2377
US

IV. Provider business mailing address

129 MAIN ST
OLD SAYBROOK CT
06475-2377
US

V. Phone/Fax

Practice location:
  • Phone: 860-395-2990
  • Fax: 860-388-4300
Mailing address:
  • Phone: 860-395-2990
  • Fax: 860-388-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. FRANK JAMES RACCIO JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 860-395-2990