Provider Demographics
NPI:1114306636
Name:LIGHTHOUSE LABS LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-242-5388
Mailing Address - Street 1:1735 KELLER SPRINGS RD
Mailing Address - Street 2:STE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-2962
Mailing Address - Country:US
Mailing Address - Phone:972-242-5388
Mailing Address - Fax:
Practice Address - Street 1:1735 KELLER SPRINGS RD STE 202
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-3006
Practice Address - Country:US
Practice Address - Phone:972-242-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2095694291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherFED TX ID