Provider Demographics
NPI:1801163282
Name:LIGHTHOUSE FAMILY CLINIC LLC
Entity type:Organization
Organization Name:LIGHTHOUSE FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:360-940-7465
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:OCEAN SHORES
Mailing Address - State:WA
Mailing Address - Zip Code:98569-1574
Mailing Address - Country:US
Mailing Address - Phone:360-940-7465
Mailing Address - Fax:
Practice Address - Street 1:114 E CHANCE A LA MER NE
Practice Address - Street 2:# 107
Practice Address - City:OCEAN SHORES
Practice Address - State:WA
Practice Address - Zip Code:98569-9202
Practice Address - Country:US
Practice Address - Phone:360-940-7465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60249842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2014973Medicaid
603-142-599OtherUBI NUMBER
603-142-599OtherUBI NUMBER