Healthcare Provider Details

I. General information

NPI: 1104903160
Provider Name (Legal Business Name): LIGHTHOUSE PAIN AND SPINE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD SUITE 5008
ST AUGUSTINE FL
32086-3707
US

IV. Provider business mailing address

PO BOX 3012
ST AUGUSTINE FL
32085-3012
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-8823
  • Fax:
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME97111
License Number StateFL

VIII. Authorized Official

Name: JOHN DOYLE
Title or Position: OWNER
Credential: MD
Phone: 904-824-4990