Provider Demographics
NPI:1184265084
Name:LIGHT PATH BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:LIGHT PATH BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-228-8651
Mailing Address - Street 1:6570 W FLAMINGO RD APT 235
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-2166
Mailing Address - Country:US
Mailing Address - Phone:929-228-8651
Mailing Address - Fax:
Practice Address - Street 1:6570 W FLAMINGO RD APT 235
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-2166
Practice Address - Country:US
Practice Address - Phone:929-228-8651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health