Healthcare Provider Details

I. General information

NPI: 1386020840
Provider Name (Legal Business Name): THE COMMUNITY LIGHTHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 ACADEMY RD NE STE 2-200
ALBUQUERQUE NM
87109-3380
US

IV. Provider business mailing address

7801 ACADEMY RD NE STE 2-200
ALBUQUERQUE NM
87109-3380
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1215022041
License Number StateNM

VIII. Authorized Official

Name: MR. BRANDON SAYLER
Title or Position: COO
Credential:
Phone: 505-273-6300