Provider Demographics
NPI:1831646629
Name:LIGHTHOUSE THERAPEUTICS
Entity Type:Organization
Organization Name:LIGHTHOUSE THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEIDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:803-900-4020
Mailing Address - Street 1:PO BOX 1238
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-1238
Mailing Address - Country:US
Mailing Address - Phone:803-900-4020
Mailing Address - Fax:803-753-9362
Practice Address - Street 1:2 PLAZA DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9385
Practice Address - Country:US
Practice Address - Phone:803-900-4020
Practice Address - Fax:803-753-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation