Provider Demographics
NPI:1770057671
Name:LIGHTHOUSE MEDICAL GROUP OF FLORIDA INC
Entity type:Organization
Organization Name:LIGHTHOUSE MEDICAL GROUP OF FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-606-3543
Mailing Address - Street 1:85 GRAND CANAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2566
Mailing Address - Country:US
Mailing Address - Phone:786-703-6967
Mailing Address - Fax:786-703-6972
Practice Address - Street 1:85 GRAND CANAL DR STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2566
Practice Address - Country:US
Practice Address - Phone:786-703-6967
Practice Address - Fax:786-703-6972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-15
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service