1376928689 NPI number — LIGHT STREET EI, LLC

Table of content: (NPI 1376928689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376928689 NPI number — LIGHT STREET EI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHT STREET EI, 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:
1376928689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 CLIPPER MILL RD
Provider Second Line Business Mailing Address:
STE 330
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21211-1948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-369-0000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 PATRIOT BLVD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026-8021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-931-8595
Provider Business Practice Location Address Fax Number:
855-837-4651
Provider Enumeration Date:
07/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MALONEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-369-0000

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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