Provider Demographics
NPI:1093865586
Name:LIGHTHOUSE HOSPICE LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:JD, LCSW
Authorized Official - Phone:801-562-2273
Mailing Address - Street 1:6794 S. 1300 E.
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2719
Mailing Address - Country:US
Mailing Address - Phone:801-562-2273
Mailing Address - Fax:
Practice Address - Street 1:6794 S 1300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2719
Practice Address - Country:US
Practice Address - Phone:801-562-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTV15693251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT461565Medicare Oscar/Certification