Provider Demographics
NPI:1457816332
Name:LIGHT MATTER SOLUTIONS LLC
Entity Type:Organization
Organization Name:LIGHT MATTER SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLIATH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-810-2308
Mailing Address - Street 1:2660 CRIMSON CANYON DR STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0846
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:333 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1914
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty