Healthcare Provider Details

I. General information

NPI: 1407770670
Provider Name (Legal Business Name): LIGHTHOUSE DIAGNOSTIC TESTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 WABASH AVE
SPRINGFIELD IL
62791-0836
US

IV. Provider business mailing address

1760 WABASH AVE
SPRINGFIELD IL
62791-0836
US

V. Phone/Fax

Practice location:
  • Phone: 217-720-7449
  • Fax:
Mailing address:
  • Phone: 217-720-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: NATE' RUSSELL
Title or Position: MANAGER
Credential:
Phone: 217-720-7449