Healthcare Provider Details

I. General information

NPI: 1881769461
Provider Name (Legal Business Name): LIGHTHOUSE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12134 AUGUSTA RD STE A
LAVONIA GA
30553-1208
US

IV. Provider business mailing address

12134 AUGUSTA RD
LAVONIA GA
30553-1208
US

V. Phone/Fax

Practice location:
  • Phone: 706-377-3349
  • Fax:
Mailing address:
  • Phone: 706-356-1422
  • Fax: 706-356-1425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042704
License Number StateGA

VIII. Authorized Official

Name: PAUL E RABER
Title or Position: OWNER PHYSICIAN
Credential: DO
Phone: 706-377-3349