Provider Demographics
NPI:1568433092
Name:LIGHTHOUSE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BURCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:603-431-0277
Mailing Address - Street 1:1 CATE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7107
Mailing Address - Country:US
Mailing Address - Phone:603-431-0277
Mailing Address - Fax:603-422-8849
Practice Address - Street 1:1 CATE ST STE 110
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7107
Practice Address - Country:US
Practice Address - Phone:603-431-0277
Practice Address - Fax:603-422-8849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1271225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0804210Y0NH04OtherBCBS
NH0803055Y0NH01OtherBCBS - DAVE BURCHUK
NH0806114Y0NH01OtherBCBS - SARAH TROOST
NH08Y003493NH01OtherBCBS
NH08Y011802NH02OtherBCBS
NHRE5893Medicare ID - Type UnspecifiedDAVID G. BURCHUK
NHRE741801Medicare PIN
NHRE891001Medicare PIN
NH0804210Y0NH04OtherBCBS
NHRE6443Medicare PIN