Provider Demographics
NPI:1790274660
Name:LIGHTHOUSE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:VANDEN AVOND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-316-0656
Mailing Address - Street 1:305 STEELE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-1266
Mailing Address - Country:US
Mailing Address - Phone:920-316-0656
Mailing Address - Fax:
Practice Address - Street 1:305 STEELE ST STE 1
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-1266
Practice Address - Country:US
Practice Address - Phone:920-316-0656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty