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General NPI Number Information
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NPI Number | 1730581117
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE CREW
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Dates
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Enumeration Date | 09/17/2014
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Last Update Date | 09/17/2014
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Provider Practice Location Address
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Address Line | 417 SW 12TH ST
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City | FORT LAUDERDALE
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State | FL
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Zip | 33315-1406
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Country | US
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Telephone | 954-522-5003
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Fax |
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Provider Business Mailing Address
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Address Line | 757 SE 17TH ST # 811
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City | FORT LAUDERDALE
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State | FL
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Zip | 33316-2960
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JIM ESCHBACH
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Credential |
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Telephone | 954-522-5003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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