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General NPI Number Information
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NPI Number | 1639668114
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Entity Type | Organization
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Legal Business Name | THE LIGHTHOUSE-HOME FOR MEDICALLY FRAGILE CHILDREN
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Dates
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Enumeration Date | 05/09/2018
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Last Update Date | 05/09/2018
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Provider Practice Location Address
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Address Line | 206 W CENTURY BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90003-4502
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Country | US
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Telephone | 310-904-4645
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Fax |
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Provider Business Mailing Address
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Address Line | 30845 BURNING TREE DR
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City | CANYON LAKE
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State | CA
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Zip | 92587-7503
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Country | US
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Telephone | 310-904-4645
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | LISA CARMELLA AMOS
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Credential |
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Telephone | 310-904-4645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0800X
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Taxonomy Name | Recovery Care Clinic/Center
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License Number |
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License Number State |
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