Provider Demographics
NPI:1801858071
Name:LIGHTHOUSE OF PINELLAS INC
Entity Type:Organization
Organization Name:LIGHTHOUSE OF PINELLAS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-544-4433
Mailing Address - Street 1:6925 112TH CIR N
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-5520
Mailing Address - Country:US
Mailing Address - Phone:727-544-4433
Mailing Address - Fax:727-544-5511
Practice Address - Street 1:6925 112TH CIR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5200
Practice Address - Country:US
Practice Address - Phone:727-544-4433
Practice Address - Fax:727-544-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880145200Medicaid
FL880147900Medicaid
FL882356100Medicaid