Provider Demographics
NPI:1114572955
Name:LIGHTHOUSE MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-891-1530
Mailing Address - Street 1:9184 WILD HORSE AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-0047
Mailing Address - Country:US
Mailing Address - Phone:770-891-1530
Mailing Address - Fax:
Practice Address - Street 1:9184 WILD HORSE AVE
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92344-0047
Practice Address - Country:US
Practice Address - Phone:770-891-1530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies