=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073299673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2023
-----------------------------------------------------
Last Update Date | 09/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 MAURY ST
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-294-9069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13803 STROH CT
-----------------------------------------------------
City | ACCOKEEK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20607-3780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-314-7187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | FITSUM A TEFERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-294-9069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------