Healthcare Provider Details

I. General information

NPI: 1235821083
Provider Name (Legal Business Name): LIGHTHOUSE SOBER SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 BISHOP LN
ELIZABETHTOWN KY
42701-9266
US

IV. Provider business mailing address

202 BISHOP LN
ELIZABETHTOWN KY
42701-9266
US

V. Phone/Fax

Practice location:
  • Phone: 270-234-0003
  • Fax: 270-360-0840
Mailing address:
  • Phone: 270-234-0003
  • Fax: 270-360-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TONY J METCALFE
Title or Position: C.E.O
Credential:
Phone: 270-370-7573