Healthcare Provider Details

I. General information

NPI: 1831045178
Provider Name (Legal Business Name): LIGHT HAVEN: A SECOND CHANCES COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 KINGS HWY
MEDFORD OR
97501-4486
US

IV. Provider business mailing address

2111 KINGS HWY
MEDFORD OR
97501-4486
US

V. Phone/Fax

Practice location:
  • Phone: 541-305-3763
  • Fax:
Mailing address:
  • Phone: 541-305-3763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN NIGHTINGALE
Title or Position: CHIEF ETHICS OFFICER
Credential:
Phone: 541-305-3763