MEDICARE: LIGHTHOUSE SUPPORT SERVICES, INC.

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
1	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	F001	FL

General Provider Information

NPI Number	:	1437127487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	826 SE SWEETBAY AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34983-4647
Country	:	US
Telephone Number	:	772-344-4954
Fax Number	:	772-344-5875

Provider Business Practice Location Address
First Line	:	826 SE SWEETBAY AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34983-4647
Country	:	US
Telephone Number	:	772-344-4954
Fax Number	:	772-344-5875

Authorized Official
Title or Position	:	CEO
Name	:	MR. RUBEN CANCEL
Credential	:
Telephone Number	:	772-344-4954

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/21/2022

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