Healthcare Provider Details

I. General information

NPI: 1043037120
Provider Name (Legal Business Name): LIGHTHOUSE INFUSIONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 NE BOTHELL WAY STE 4
KENMORE WA
98028-9400
US

IV. Provider business mailing address

5701 NE BOTHELL WAY STE 4
KENMORE WA
98028-9400
US

V. Phone/Fax

Practice location:
  • Phone: 425-835-2363
  • Fax: 425-368-7634
Mailing address:
  • Phone: 425-835-2363
  • Fax: 425-368-7634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LIANA REN
Title or Position: OWNER / MEDICAL DIRECTOR
Credential: CRNA, ARNP
Phone: 425-835-2363