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General NPI Number Information
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NPI Number | 1730482845
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Entity Type | Organization
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Legal Business Name | LIGHT HOUSE AMBULATORY CLINIC LLC
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Dates
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Enumeration Date | 12/10/2010
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Last Update Date | 12/10/2010
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Provider Practice Location Address
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Address Line | 121 W FLORENCE BLVD SUITE B
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City | CASA GRANDE
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State | AZ
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Zip | 85122-4089
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Country | US
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Telephone | 520-423-8334
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Fax | 520-421-2877
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Provider Business Mailing Address
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Address Line | 121 W FLORENCE BLVD SUITE B
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City | CASA GRANDE
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State | AZ
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Zip | 85122-4089
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Country | US
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Telephone | 520-423-8334
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Fax | 520-421-2877
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Authorized Official
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Title or Position | OWNER-ADMINISTRATOR
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Name | MS. FLORENCE ADENIKE OLADOKUN
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Credential | RN, FNP
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Telephone | 520-421-8334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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