Provider Demographics
NPI:1851924088
Name:FIRST LIGHT CLINIC LLC
Entity Type:Organization
Organization Name:FIRST LIGHT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-400-7841
Mailing Address - Street 1:706 CAMPBELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-3534
Mailing Address - Country:US
Mailing Address - Phone:540-400-7841
Mailing Address - Fax:540-400-8177
Practice Address - Street 1:706 CAMPBELL AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-3534
Practice Address - Country:US
Practice Address - Phone:540-400-7841
Practice Address - Fax:540-400-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center