Provider Demographics
NPI:1154320299
Name:LIGHTBRIDGE HOSPICE, LLC
Entity Type:Organization
Organization Name:LIGHTBRIDGE HOSPICE, LLC
Other - Org Name:LIGHTBRIDGE HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDLEN
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:858-458-2992
Mailing Address - Street 1:6155 CORNERSTONE CT E
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4737
Mailing Address - Country:US
Mailing Address - Phone:858-458-2992
Mailing Address - Fax:858-458-3655
Practice Address - Street 1:6155 CORNERSTONE COURT EAST
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4737
Practice Address - Country:US
Practice Address - Phone:858-458-2992
Practice Address - Fax:858-458-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000772251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHPC01763FMedicaid
CA051763Medicare ID - Type UnspecifiedHOSPICE