Provider Demographics
NPI:1235311291
Name:A BEAM OF LIGHT LLC
Entity Type:Organization
Organization Name:A BEAM OF LIGHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:REVADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-328-1627
Mailing Address - Street 1:P O BOX 925
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073
Mailing Address - Country:US
Mailing Address - Phone:504-328-1627
Mailing Address - Fax:504-328-1467
Practice Address - Street 1:5201 WESTBANK EXPRESSWAY
Practice Address - Street 2:SUITE 315
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-328-1627
Practice Address - Fax:504-328-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA97933747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1170399Medicaid