1487093944 NPI number — LIGHTHOUSE CHILD & FAMILY SERVICES

Table of content: (NPI 1487093944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487093944 NPI number — LIGHTHOUSE CHILD & FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE CHILD & FAMILY SERVICES
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:
1487093944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 3RD AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILACA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56353-1555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-983-2335
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 3RD AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILACA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56353-1555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-983-2335
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HANENBURG
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CLINICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
320-983-2335

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  1689861197 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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