Provider Demographics
NPI:1053546093
Name:LIGHTHOUSE COMMUNITY OUTREACH, INC.
Entity type:Organization
Organization Name:LIGHTHOUSE COMMUNITY OUTREACH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTUVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-401-7600
Mailing Address - Street 1:1976 E 103RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3124
Mailing Address - Country:US
Mailing Address - Phone:323-567-2285
Mailing Address - Fax:323-567-2622
Practice Address - Street 1:1968 E 103RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3124
Practice Address - Country:US
Practice Address - Phone:323-567-2285
Practice Address - Fax:323-567-2622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization