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General NPI Number Information
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NPI Number | 1457816332
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Entity Type | Organization
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Legal Business Name | LIGHT MATTER SOLUTIONS LLC
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Dates
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Enumeration Date | 02/05/2019
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Last Update Date | 02/05/2019
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Provider Practice Location Address
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Address Line | 333 E 2ND ST
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City | RICHLAND CENTER
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State | WI
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Zip | 53581-1914
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Country | US
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Telephone | 702-453-3799
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Fax | 702-453-5741
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Provider Business Mailing Address
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Address Line | 2660 CRIMSON CANYON DR STE 130
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City | LAS VEGAS
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State | NV
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Zip | 89128-0846
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Country | US
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Telephone | 702-453-3799
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Fax | 702-453-5741
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Authorized Official
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Title or Position | SOLE OWNER
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Name | JACOB KALLIATH
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Credential | DO
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Telephone | 256-810-2308
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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