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NPI Code Detail

MEDICARE: LIGHTHOUSE LABS LLC

MEDICARE: LIGHTHOUSE LABS LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1291U00000XClinical Medical Laboratory45D2095694TX

General Provider Information

NPI Number : 1114306636
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIGHTHOUSE LABS LLC
Provider Business Mailing Address
First Line : 1735 KELLER SPRINGS RD
Second Line : STE 202
City : CARROLLTON
State : TX
Zip : 75006-2962
Country : US
Telephone Number : 972-242-5388
Fax Number :
Provider Business Practice Location Address
First Line : 1735 KELLER SPRINGS RD STE 202
Second Line :
City : CARROLLTON
State : TX
Zip : 75006-3006
Country : US
Telephone Number : 972-242-5388
Fax Number :
Authorized Official
Title or Position : OWNER
Name : JASON BOURQUE
Credential :
Telephone Number : 972-242-5388
Provider Enumeration Date : 05/29/2015
Last Update Date : 06/20/2018

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