1801163282 NPI number — LIGHTHOUSE FAMILY CLINIC LLC

Table of content: (NPI 1801163282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801163282 NPI number — LIGHTHOUSE FAMILY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE FAMILY CLINIC LLC
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:
1801163282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1574
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEAN SHORES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98569-1574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-940-7465
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 E CHANCE A LA MER NE
Provider Second Line Business Practice Location Address:
# 107
Provider Business Practice Location Address City Name:
OCEAN SHORES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98569-9202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-940-7465
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-940-7465

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP60249842 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2014973 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 603-142-599 . This is a "UBI NUMBER" identifier . This identifiers is of the category "OTHER".




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