Provider Demographics
NPI:1609410174
Name:LITE SUPPLY
Entity Type:Organization
Organization Name:LITE SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-849-4835
Mailing Address - Street 1:2087 E 30 N
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-5893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2087 E 30 N
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5893
Practice Address - Country:US
Practice Address - Phone:347-849-4835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies