MEDICARE: LIGHTHOUSE BY P&C 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1821691445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE BY P&C LLC

Provider Business Mailing Address
First Line	:	5300 N BREASWOOD BLVD
Second Line	:	STE 4, #5020
City	:	HOUSTON
State	:	TX
Zip	:	77096-4657
Country	:	US
Telephone Number	:	832-654-6158
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 N BREASWOOD BLVD
Second Line	:	STE 4, #5020
City	:	HOUSTON
State	:	TX
Zip	:	77096-4657
Country	:	US
Telephone Number	:	832-654-6158
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	CYNISE HYLTON
Credential	:	NP
Telephone Number	:	816-522-2528

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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