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General NPI Number Information
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NPI Number | 1053546093
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE COMMUNITY OUTREACH, INC.
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Dates
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Enumeration Date | 05/20/2009
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Last Update Date | 05/20/2009
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Provider Practice Location Address
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Address Line | 1968 E 103RD ST
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City | LOS ANGELES
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State | CA
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Zip | 90002-3124
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Country | US
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Telephone | 323-567-2285
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Fax | 323-567-2622
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Provider Business Mailing Address
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Address Line | 1976 E 103RD ST
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City | LOS ANGELES
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State | CA
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Zip | 90002-3124
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Country | US
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Telephone | 323-567-2285
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Fax | 323-567-2622
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Authorized Official
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Title or Position | EXECUTUVE DIRECTOR
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Name | MS. SHELLY KAY BYNUM
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Credential |
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Telephone | 323-401-7600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State | CA
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