Provider Demographics
NPI:1265718332
Name:LIGHTHOUSE PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:LIGHTHOUSE PHYSICAL THERAPY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:NICODEMO-CAPRA
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PT
Authorized Official - Phone:516-808-4230
Mailing Address - Street 1:2 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1001
Mailing Address - Country:US
Mailing Address - Phone:516-808-4230
Mailing Address - Fax:631-331-0320
Practice Address - Street 1:2 WALTON WAY
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1001
Practice Address - Country:US
Practice Address - Phone:516-808-4230
Practice Address - Fax:631-331-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty