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General NPI Number Information
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NPI Number | 1700246139
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE RECOVERY
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Dates
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Enumeration Date | 02/26/2016
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 210 S 5TH ST SUITE 10
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City | ST CHARLES
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State | IL
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Zip | 60174-2764
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Country | US
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Telephone | 630-940-2468
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Fax |
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Provider Business Mailing Address
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Address Line | 210 S 5TH ST SUITE 10
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City | ST CHARLES
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State | IL
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Zip | 60174-2764
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Country | US
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Telephone | 630-940-2468
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARTIN KEIFER
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Credential |
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Telephone | 630-940-2468
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | A-6255-0001-A
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License Number State | IL
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