Provider Demographics
NPI:1821742438
Name:BEACON OF LIGHT CARE LLC
Entity Type:Organization
Organization Name:BEACON OF LIGHT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-292-7555
Mailing Address - Street 1:2424 FRANKLIN ST # 203
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4562
Mailing Address - Country:US
Mailing Address - Phone:219-292-7555
Mailing Address - Fax:219-814-4941
Practice Address - Street 1:2424 FRANKLIN ST # 203
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4562
Practice Address - Country:US
Practice Address - Phone:219-292-7555
Practice Address - Fax:219-814-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300055484Medicaid