Provider Demographics
NPI:1730482845
Name:LIGHT HOUSE AMBULATORY CLINIC LLC
Entity Type:Organization
Organization Name:LIGHT HOUSE AMBULATORY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:ADENIKE
Authorized Official - Last Name:OLADOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, FNP
Authorized Official - Phone:520-421-8334
Mailing Address - Street 1:121 W FLORENCE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-4089
Mailing Address - Country:US
Mailing Address - Phone:520-423-8334
Mailing Address - Fax:520-421-2877
Practice Address - Street 1:121 W FLORENCE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4089
Practice Address - Country:US
Practice Address - Phone:520-423-8334
Practice Address - Fax:520-421-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care