1104926351 NPI number — LIGHTHOUSE HOSPICE OF ALABAMA

Table of content: (NPI 1104926351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104926351 NPI number — LIGHTHOUSE HOSPICE OF ALABAMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE HOSPICE OF ALABAMA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104926351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 965
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36081-0965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-566-4357
Provider Business Mailing Address Fax Number:
334-566-2220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 S BRUNDIDGE ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36081-3331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-566-4357
Provider Business Practice Location Address Fax Number:
334-566-2220
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OUTLAW
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
334-566-4357

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  11735 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PIC1636E , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 013221 . This is a "BCBS OF AL PROVIDER #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".