MEDICARE: LIGHTHOUSE CLINICAL 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	103G00000X	Clinical Neuropsychologist	1788	TX
2	103G00000X	Clinical Neuropsychologist	2998	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2998	OTHER	CO	DORA
2	1788	OTHER	TX	STATE BOARD OF EXAMINERS

General Provider Information

NPI Number	:	1871788349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE CLINICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	2500 N CIRCLE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1184
Country	:	US
Telephone Number	:	719-636-3784
Fax Number	:	719-630-3211

Provider Business Practice Location Address
First Line	:	2500 N CIRCLE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1184
Country	:	US
Telephone Number	:	719-636-3784
Fax Number	:	719-630-3211

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BOB GANT
Credential	:	PHD
Telephone Number	:	719-636-3784

Provider Enumeration Date	:	09/07/2007
Last Update Date	:	09/07/2007

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