Healthcare Provider Details

I. General information

NPI: 1588290324
Provider Name (Legal Business Name): LIGHTHOUSE PRIMARY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MAIN ST STE 101
NORTH READING MA
01864-1326
US

IV. Provider business mailing address

315 MAIN ST STE 101
NORTH READING MA
01864-1326
US

V. Phone/Fax

Practice location:
  • Phone: 978-276-0100
  • Fax: 978-276-0041
Mailing address:
  • Phone: 978-276-0100
  • Fax: 978-276-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH P MCWHA
Title or Position: PRESIDENT
Credential: MD
Phone: 978-276-0100