Healthcare Provider Details

I. General information

NPI: 1346150562
Provider Name (Legal Business Name): BRIGHT LIGHTHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MAIN ST STE 201C
SOUTH PORTLAND ME
04106-5448
US

IV. Provider business mailing address

650 MAIN ST STE 201C
SOUTH PORTLAND ME
04106-5448
US

V. Phone/Fax

Practice location:
  • Phone: 207-317-7412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: JACKY B BOKUNDJA
Title or Position: DIRECTOR
Credential:
Phone: 207-317-7412