Provider Demographics
NPI:1437127487
Name:LIGHTHOUSE SUPPORT SERVICES, INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE SUPPORT SERVICES, INC.
Other - Org Name:LIGHTHOUSE GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANCEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-344-4954
Mailing Address - Street 1:826 SE SWEETBAY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4647
Mailing Address - Country:US
Mailing Address - Phone:772-344-4954
Mailing Address - Fax:772-344-5875
Practice Address - Street 1:826 SE SWEETBAY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-4647
Practice Address - Country:US
Practice Address - Phone:772-344-4954
Practice Address - Fax:772-344-5875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF0013104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances