Provider Demographics
NPI:1700246139
Name:LIGHTHOUSE RECOVERY
Entity Type:Organization
Organization Name:LIGHTHOUSE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEIFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-940-2468
Mailing Address - Street 1:210 S 5TH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2764
Mailing Address - Country:US
Mailing Address - Phone:630-940-2468
Mailing Address - Fax:
Practice Address - Street 1:210 S 5TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2764
Practice Address - Country:US
Practice Address - Phone:630-940-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-6255-0001-A261QR0405X, 276400000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit