Healthcare Provider Details

I. General information

NPI: 1639495278
Provider Name (Legal Business Name): LIGHTHOUSE CHIROPRACTIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 ALLENS AVE
PROVIDENCE RI
02905-5412
US

IV. Provider business mailing address

PO BOX 9117
WARWICK RI
02889-0117
US

V. Phone/Fax

Practice location:
  • Phone: 401-751-6568
  • Fax:
Mailing address:
  • Phone: 401-751-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number346
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD14078
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD14078
License Number StateRI

VIII. Authorized Official

Name: RONALD TYSZKOWSKI
Title or Position: PRESIDENT
Credential:
Phone: 401-490-0494