Healthcare Provider Details

I. General information

NPI: 1780974998
Provider Name (Legal Business Name): LIGHT MOUNTAIN HEALTHWORKS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2011
Last Update Date: 04/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 HIDDEN TRAIL CT SW
BEMIDJI MN
56601-2569
US

IV. Provider business mailing address

502 HIDDEN TRAIL CT SW
BEMIDJI MN
56601-2569
US

V. Phone/Fax

Practice location:
  • Phone: 218-759-0835
  • Fax: 218-759-0835
Mailing address:
  • Phone: 218-759-0835
  • Fax: 218-759-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberR107370-6
License Number StateMN

VIII. Authorized Official

Name: MS. JANET ANN LISTEBARGER
Title or Position: PRESIDENT
Credential: RN, MT
Phone: 218-759-0835