=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063373835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2025
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 S 5TH ST STE 10
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-677-5982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 S 5TH ST STE 10
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-940-2468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARTIN KEIFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-940-2468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083A0300X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------