Healthcare Provider Details

I. General information

NPI: 1558969105
Provider Name (Legal Business Name): LIGHTHOUSE CLOVER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 WASHINGTON ST
COLUMBIA NJ
07832-2324
US

IV. Provider business mailing address

180 HARBORVIEW N
LAWRENCE NY
11559-1904
US

V. Phone/Fax

Practice location:
  • Phone: 908-496-4307
  • Fax:
Mailing address:
  • Phone: 516-680-7687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DOV LEBOVIC
Title or Position: MEMBER
Credential: MSM LNHA
Phone: 516-680-7687