MEDICARE: RAYFORD LIGHTNER IV M.S.

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	222Q00000X	Developmental Therapist
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1629493127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYFORD LIGHTNER IV M.S.

Provider Business Mailing Address
First Line	:	PO BOX 65516
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-0009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 VANDERFORD RD N
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-5969
Country	:	US
Telephone Number	:	256-520-3234
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2014
Last Update Date	:	01/22/2018

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