MEDICARE: LIGHT HOUSE SERVICES 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
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1457121659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT HOUSE SERVICES LLC

Provider Business Mailing Address
First Line	:	5732 SALT ROCK ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-1326
Country	:	US
Telephone Number	:	702-884-6266
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 W CHEYENNE AVE STE 60
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7850
Country	:	US
Telephone Number	:	702-633-7923
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTICE DEZIRAE DOUGLAS
Credential	:
Telephone Number	:	702-884-6266

Provider Enumeration Date	:	01/08/2024
Last Update Date	:	01/08/2024

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Directions to “LIGHT HOUSE SERVICES LLC ” Practice Location

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