Provider Demographics
NPI:1639668114
Name:THE LIGHTHOUSE-HOME FOR MEDICALLY FRAGILE CHILDREN
Entity Type:Organization
Organization Name:THE LIGHTHOUSE-HOME FOR MEDICALLY FRAGILE CHILDREN
Other - Org Name:CENTURY LIGHTHOUSE RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CARMELLA
Authorized Official - Last Name:AMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-904-4645
Mailing Address - Street 1:30845 BURNING TREE DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7503
Mailing Address - Country:US
Mailing Address - Phone:310-904-4645
Mailing Address - Fax:
Practice Address - Street 1:206 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-4502
Practice Address - Country:US
Practice Address - Phone:310-904-4645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care