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General NPI Number Information
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NPI Number | 1578774543
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE HOME CARE
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 1805 S 25TH ST STE B
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City | FORT PIERCE
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State | FL
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Zip | 34947-4752
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Country | US
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Telephone | 772-466-9199
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Fax | 772-466-4776
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Provider Business Mailing Address
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Address Line | 1805 S 25TH ST STE B
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City | FORT PIERCE
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State | FL
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Zip | 34947-4752
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Country | US
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Telephone | 772-466-9199
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Fax | 772-466-4776
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CHRYSTAL BAKER FASSOLD
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Credential |
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Telephone | 772-466-9199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | NR30211217
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License Number State | FL
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