Provider Demographics
NPI:1720653355
Name:LYGHT BULB MOMENTS LLC
Entity Type:Organization
Organization Name:LYGHT BULB MOMENTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:TINEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-701-4679
Mailing Address - Street 1:12247 BIG CANOE
Mailing Address - Street 2:
Mailing Address - City:BIG CANOE
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5161
Mailing Address - Country:US
Mailing Address - Phone:678-701-4679
Mailing Address - Fax:888-701-4679
Practice Address - Street 1:8 CLIFF ST
Practice Address - Street 2:
Practice Address - City:PROCTOR
Practice Address - State:VT
Practice Address - Zip Code:05765-1102
Practice Address - Country:US
Practice Address - Phone:678-701-4679
Practice Address - Fax:888-701-4679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty