Healthcare Provider Details

I. General information

NPI: 1194177378
Provider Name (Legal Business Name): LIGHT FOR LIFE THERAPY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 FONTAINEBLEAU BLVD STE 130
MIAMI FL
33172-7011
US

IV. Provider business mailing address

275 FONTAINEBLEAU BLVD STE 130
MIAMI FL
33172-4591
US

V. Phone/Fax

Practice location:
  • Phone: 786-439-5835
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State

VIII. Authorized Official

Name: JANET L GONZALEZ
Title or Position: OWNER
Credential:
Phone: 786-439-5835