Provider Demographics
NPI:1609577311
Name:LAUREL LIGHT LLC.
Entity Type:Organization
Organization Name:LAUREL LIGHT LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-687-9008
Mailing Address - Street 1:801 BIRCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-4015
Mailing Address - Country:US
Mailing Address - Phone:703-955-0587
Mailing Address - Fax:
Practice Address - Street 1:801 BIRCHFIELD DR
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-4015
Practice Address - Country:US
Practice Address - Phone:703-955-0587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAUREL LIGHT LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder