Healthcare Provider Details

I. General information

NPI: 1447549621
Provider Name (Legal Business Name): LIGHTHOUSE FOSTER CARE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E 100 S SUITE #204
ST GEORGE UT
84770-2318
US

IV. Provider business mailing address

50 E 100 S SUITE #204
ST GEORGE UT
84770-2318
US

V. Phone/Fax

Practice location:
  • Phone: 435-229-4889
  • Fax: 877-628-3606
Mailing address:
  • Phone: 435-229-4889
  • Fax: 877-628-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number17321
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number17746
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number17746
License Number StateUT

VIII. Authorized Official

Name: MR. JOSEPH TAMSAMOA AHQUIN SR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 435-229-4889